We urge you to complete this information prior to your visit, but if you cannot, then please plan to arrive at lease 15 minutes prior to your appointment time. We will make every effort to accommodate late arrivals, but it may be necessary to reschedule those arriving late in order to keep other patients appointment on time. If you find that you need to cancel or reschedule this appointment, or any subsequent follow-up appointment, we ask that you contact our office at least 24 hours in advance.

STEP #1 - Patient Registration

Last Name: First Name: Middle Name: D.O.B. (mm/dd/yy): Mother / Guardian's Name: Mother / Guardian D.O.B.: (mm/dd/yy) SSN #: CA Lic #: Address: City: State: Zip: Employer's Name:     Address:     Home Phone: Work Phone: Mobile Phone: Email: Father / Guardian's Name: Father / Guardian D.O.B.: (mm/dd/yy): SSN #: CA Lic #: Address: City: State: Zip: Employer's Name:     Address:     Home Phone: Work Phone: Mobile Phone: Email:   In order to establish optimal relations with your patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of financial policies of this office.  PAYMENT IS EXPECTED FROM YOU AT THE TIME OF SERVICE FOR "YOUR PART" OF THE CHARGES.  WE ACCEPT VISA AND MASTERCARD FOR YOUR CONVENIENCE.  Your signature will be required on this form when you visit the office.  By checking the box below indicates that you understand and accept this policy.  Further, by checking the box below it authorizes the Doctor to release such medical information necessary to process your insurance claims (if any).  You herein authorize payment of medical benefits to the Doctor when an assigned claim is filed. I agree to these terms of service.

STEP #2 - Download and Print Additional Medical Forms