If you have a newborn or are transferring your child(ren) from another practice we request that you complete our Patient Registration Form, Medical Records Transfer form, and Family Medical History Form prior to your first appointment. We ask that you either fax, mail, or email the Patient Registration Form, Family Medical History Form, and a copy of your insurance card in to us at (818) 783-3115. If emailing, please send to firstname.lastname@example.org. Please send the Medical Records Transfer Form directly to your child's previous physician's office. If your child has been seen by other doctors, please do your best to have medical and immunization records sent to us at least 5 days prior to your child's scheduled appointment so that our providers can review your child's chart before that time.
Please take the opportunity to download and print the following three PDF forms. Downloading these forms requires that you have Adobe Acrobat Reader. If you do not have this software, please click here for a free download from Adobe or call the office and we will mail them to you.
Patient Registration Form
Fill in this form and the Family Medical History Form below and a copy of your child's insurance information as completely as possible. Then sign and either fax (818) 783-3115, mail or email to our office prior to your child's visit. You may email the information to email@example.com.
Medical Record Transfer Form
If you have not done so already, please complete this form, sign it, and send it to your child(ren)'s previous physician's office. If your child has a complicated medical history, we recommend that you also send this form to any consultants involved in the care of your child(ren).
Family Medical History Form
Patient Medical History Form
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