NEW PATIENT FORMS
Want to make your first office visit a little easier?
We have provided the following forms for you to securely fill in and submit to us electronically. Alternatively, you can download and PRINT the forms, fill them out at your leisure, and bring them with you on your next visit!
Things to know before you go:
Please arrive 20 minutes PRIOR to your appointment to give our staff the time to place your information in our electronic medical record system.
If you have sent your information to us electronically, please arrive 10 minutes prior to your scheduled visit time.
Please remember to bring:
- Current Health Insurance Card/Information
- Immunization Record
- List of your child’s current medication(s)
Co-pays and Other Payments: Your co-payment is required at the time of service. We accept Visa, MasterCard, American Express, Checks and Debit Cards
If you are submitting a form electronically, you will receive an email shortly after your initial submission to verify your identity. Please click on the link in that email to complete the transaction.
Your signing process will not finish until you complete this verification step.
Please also be sure to add firstname.lastname@example.org to your Safe Senders List in order to ensure email delivery. Information on how to do this can be found here.
➽ Pediatric New Patient Form
➽ Pediatric Portal Enrollment Form
➽ Pediatric Portal Opt-Out Form
➽ Pediatric Medical Records Release Form*
(If you would like your previous records sent to EMG, please complete this form and submit prior to your appointment.)
➽ Pediatric Notice of Privacy Practices
➽ Pediatric Member Rights & Responsibilities
➽ The California Immunization Registry Information
➽ Pediatric Vaccine Statement