Please complete the four required forms. Most take a few minutes. The intake questionnaire is longer, and your answers cannot be saved partway, so set aside time to finish it in one sitting. It helps to have your insurance card and a list of your current and past medications ready.
Required for new patients
Intake Questionnaire Required
Patient information, medical history, current medications, symptoms, and personal history. The longest form, with 16 sections.
Agreement of Care Required
Appointment policies, the missed appointment fee, and billing and payment responsibilities.
Telemedicine Consent Required
For video visits, which is how most appointments are held. You must live in California and be physically in California during each video visit.
Privacy Practices Acknowledgment Required
Confirms you've received our Notice of Privacy Practices.
Optional / as needed
Communication Consent Optional
Choose whether we may contact you by text message, email, or both, for appointment reminders, refill notifications, billing and payment reminders, questionnaires, and other messages about your care.
Release of Information As needed
Only if you want us to send or request records: it lets us share your health information with a person or organization you name, or lets another provider send your records to us.
Paying without insurance? You have the right to a Good Faith Estimate of your costs.
Prefer paper forms?
Download and print the forms, then fax them to (888) 965-0556.
Required
- Intake Questionnaire (PDF)
- Agreement of Care (PDF)
- Telemedicine Consent (PDF)
- Privacy Practices Acknowledgment (PDF)
Optional / as needed
- Communication Consent (PDF)
- Release of Information (PDF) — only if you want us to send or request records
To read and keep, with no need to fax it back: Notice of Privacy Practices (PDF)
Language assistance and accessible formats
Free language assistance services, and free auxiliary aids and services such as qualified interpreters and information in accessible formats, are available to you. Call (925) 289-9022 (TTY: 711) or ask our staff. See our notice of nondiscrimination.