714-965-2500

M-F 8:30 am – 5:00 pm

SAT 9:00 am – 11:00 am

SUN 9:30 am – 11:00 am

Patient Forms

Want to make your next office visit a little easier?

We’ve provided the following forms for you to fill in and (securely) electronically submit to us. Alternatively, you can download and PRINT the forms, fill them out at your leisure, and bring them with you on your next visit.

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 echosign@echosign.com to your Safe Senders List in order to ensure email delivery. Information on how to do this can be found here.

Adult Patient Forms

Individual Forms:
➽ Adult Patient Registration Form
Submit Electronically
➽ Adult Medical History Questionnaire
Submit Electronically
➽ Adult Consent to Use and Disclosure of Health Information Form
Submit Electronically
➽ Adult Patient Financial Policy and Agreement Form
Submit Electronically
➽ Adult Change of Contact Information Form
Submit Electronically
Supplemental/Optional Forms:
➽ Adult Portal Enrollment Form
Submit Electronically
➽ Adult Portal Opt-Out Form
Submit Electronically
➽ Adult Medical Records Release Form*

(If you would like your previous records sent to EMG, please complete this form and submit prior to your appointment.)

Submit Electronically
➽ Benzodiazepine Agreement

Notices:
➽ Adult Notice of Privacy Practices
➽ Adult Member Rights & Responsibilities

Pediatric Patient Forms

Individual Forms:
➽ Pediatric Patient Registration Form
Submit Electronically
➽ Pediatric Medical History Questionnaire
Submit Electronically
➽ Pediatric Consent to Use and Disclosure of Health Information Form
Submit Electronically
➽ Pediatric Patient Financial Policy and Agreement Form
Submit Electronically
➽ Pediatric Change of Contact Information Form
Submit Electronically
Supplemental/Optional Forms:
➽ Pediatric Portal Enrollment Form
Submit Electronically
➽ Pediatric Portal Opt-Out Form
Submit Electronically
➽ 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.)

Submit Electronically
Notices:
➽ Pediatric Notice of Privacy Practices
➽ Pediatric Member Rights & Responsibilities
➽ The California Immunization Registry Information
➽ Pediatric Vaccine Statement

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