Patient Registration

At the time the patient appointment is confirmed (often the same day the appointment is made), demographic and insurance information will be obtained (Pre-registration). As a convenience, this information can be submitted by the patient at the time the appointment is made - simply download the Patient Information Form and fax the completed form back to our office at (323) 442-5301.

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Pre-Registration

  1. Download and complete the Patient Information Form.
  2. Fax to (323) 442-5301 when you make you first appointment. Bring the signed original with you on the day of the consultation visit.
*Note - This information will only need to be obtained once (prior to your initial consultation visit). However, the information will be re-verified at the time of each follow-up visit.

Initial Visit

On the day of the initial patient consultation visit, patients will be asked to complete three forms as part of the registration process, in addition to the New Patient History Form (questionnaire). These three forms are the HIPPA (Patient Privacy) Form, Consent for Medical Treatment Form, and Medication Refill Protocol Form. These forms must be completed and signed by the patient (or patient's legal guardian, if applicable) prior to being seen and treated by the physician(s) and nurses. The HIPPA form is to be completed and signed after the patient has received and read HIPPA (Notice of Patient Privacy) Policy.

As a convenience, these notices and forms can be downloaded, printed, read, and filled out prior to the appointment, so as to save time on the day of the office visit. Simply bring the completed and signed forms on the day of the office appointment.

Registration (for Initial Visit)

  1. Download and read the HIPPA (Notice of Patient Privacy) Policy
  2. Download, complete, and sign the following forms. Bring these forms with you on the day of your consultation visit.

New Patient Forms

Follow-Up Visits

When patients return for a follow-up visit, a new HIPPA Form and Consent for Medical Treatment Form, as well as a Follow-Up Patient History Form (questionnaire) must be completed and signed prior to being seen and treated by the physician(s) and nurses.

As a convenience, these forms can also be downloaded, printed, and filled out prior to the appointment, so as to save time on the day of the office visit. Simply bring the completed and signed forms on the day of the office appointment.

Registration (for Follow-Up Visits)

  1. Download and read the HIPPA (Notice of Patient Privacy) Policy
  2. Download, complete, and sign the following forms. Bring these forms with you on the day of your consultation visit

Follow-Up Patient Forms