Preparing for Your First Visit

If you wish to become a patient, call us so we can answer any questions you might have, and schedule your appointment.

Please fill out the "New Patient" form which includes questions about your medical history and send/fax that to us before your appointment. This will help make the time we spend together more efficient.

It is also helpful to obtain copies of your medical records, labs and studies ahead of time and fax/send them to our office. Print, fill out the "Obtain Your Medical Records" form and send to your previous health care providers and specialists in order to obtain your records prior to your visit. Call us at 626-796-3413 if you have any questions.

New Patients Forms

  1. Click on the appropriate form (below) to download a copy to your computer.

  2. Print the form then complete it as best as possible.

  3. Bring it with you when you come in, or better, fax it to us before your visit at 626-737-1481



Female Patient Form


FEMALE_Initial_Visit_Intake_Form



Male Patient Form


MALE_Initial_Visit_Intake_Form


Male or Female under 18 years of age Form


PEDIATRIC_Initial_Visit_Medical__Demographic_Information

Out of Network Insurance Benefits Form

This form will help you determine what your insurance benefits are and consequently, what your out-of-pocket costs will be for a typical visit at our office. You should know that some policies get very complex especially in regards to preventive care. So you should also ask about annual physicals and other preventative medicine. And remember that we are an “OUT-OF-NETWORK” provider. Have your insurance card or policy handy when you call their customer service number and ask for the following information.

OUT_of_network_quote_of_benefits


Form to Obtain Prior Medical Records

This form will help us get the bigger picture of what procedures have been done, whom you have seen, course of treatment, etc.


Medical_Records_Release_TO_us

Any questions or comments?

We look forward to working with you.

Call us at 626-796-3413 if you have any questions.

You may fax us these forms at 626-737-1481