Patient Forms

Preparing for Your First Visit

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

Please fill out the appropriate “Initial Visit” 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 or send them to our office. Print and fill out the “Form to Obtain Prior Medical Records” and send this 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.

Patients Forms

These are PDF forms. If you cannot open them, download the free Adobe Acrobat Reader.

FEMALE Initial Visit Intake Form
MALE Initial Visit Intake Form
PEDIATRIC Initial Visit Intake Form (for patients under 18 years of age)

DIET Questionnaire Form

Consent and Financial Policy Form

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.

OUT of Network Quote of Benefits

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 user this form to help guide your conversation.

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 these forms to us at 626-737-1481.