New Patients

Southern California Endocrine Medical Group, P. M. C.

1801 W. Romneya Dr., Suite 103, Anaheim, CA 92801 (714) 535-0000

Registration forms (For new patients)

New Patients only:

A) Please print out forms #1-4 below, fill in as much information as possible, sign, and bring them with you to your appointment. (If you are unable to do so then please arrive 20 minutes earlier than your appointment time)

B) Please also bring the following to your first visit:

      * ID Card or Drivers license card (Mandatory on 1st visit)
      * Insurance or Medicare Card (Mandatory on 1st visit)
      * Your medications (or a list of your medications,doses,and frequency)
     * Recent lab reports
      * Radiology reports
      * and glucometer or blood sugar log book (if applicable).

1) Registration Form    (Please print)

2) Contact Information Release Form (Please print)

3) Notice of Privacy Practices Acknowledgement of Receipt (Please print)

4) Medical History Questionaire (2 pages) (Please print)

5) Notice of Privacy Practices Handout

6) Patient Rights & Responsibilities Form

Please give at least 24 hours notice if you need to cancel or to re-schedule your appointment.

SPANISH:

1) Questionario de Salud (Por favor imprimir)