Patient Intake Form & Health History

Step 3: Please complete the following form. If you have any questions, please contact our office:
(888) 377-4483

Available in Español and 中文.

Tips for using this form:

  • Be ready with medical & insurance information for both yourself and your partner (if applicable).
  • Ensure any images are saved on your computer or phone before uploading them to this form. If they are not saved, you may receive an error message.
  • Save your progress on the form at any time by using the button at the bottom of the form. Please save your password for the form if you use this feature. We cannot recover your password.
  • Complete the form when you have a stable internet connection. Weak connections may cause problems with saving or submitting the form.

Thank you for completing your new patient paperwork! We look forward to seeing you soon.