MLMD New Patient Registration

Patient Agreement

Please read the Agreement, Select an Option, and Sign. A copy of the signed Agreement will be emailed to you. Once you've completed the form, Dr. Long will reach out to you to schedule your appointment.
One time Consultation for $400/hour. Select CONCIERGE HOUR Option A if you are interested in a House Call for a one time consultation. One time consultations include Urgent Care, and Consultative Medicine.

Primary Care for $400/month. Select CONCIERGE ONE Option B or C if you are interested in House Call based Primary Care.

Facility Care. Select CONCIERGE TWO Option D or E if you are interested in receiving advocacy and visits at a facility, such as a long term care home, rehab/SNF nursing home, or hospital.

Select Option A if you are unsure. You may always change your chosen Option at the end of the initial consultation.
Patient Agreement
Select an Option
Signature

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Patient Information Sheet

Information about you and your insurance. Your ID and insurance card will be scanned at your first appointment.
(Last)
(First)
(MI)
Marital Status
Address where you receive bills

Address (Billing)

Street Address Line 2

CityState

Zip CodeCountry
Address where you reside

Physical Address (If Different)

Street Address Line 2

CityState

Zip
Date of Birth*

MonthDayYear
Date
Social Security #
Email*
example@example.com
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Employer
Address
City
State
Zip
Occupation
Whom may we contact in case of emergency*
First and Last Name
Relationship*
How is this person related to you? Spouse, Sister, Brother...
Phone*

Area CodePhone Number
Are there other members of the immediate family who have already been to this office?
Yes/No
If so, list their names
Patient's Insurance ID#
Subscriber (whose job provides plan?):
(Last)
(First)
(MI)
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Social Security #
Insurance Company
ID #
Group#
Patient's Insurance ID#
Secondary Insurance, if any

Subscriber: (Last) Subscriber's Date of Birth:
(Last)
(First)
(MI)
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Social Security #
Insurance Company
ID #
Group #
AUTHORIZATION TO PAY INSURANCE BENEFITS/CONSENT FOR TREATMENT

Ifrequired. I hereby authorize payment directly to the physician responsible for my care. I understand that I am financially responsible to my physician for all fees incurred and for fees not covered by this authorization. I authorize the release of my medical information to my third party payor in order to obtain payment. I hereby authorize the physician to release any medical information required for my examination or treatment. I understand that payment is expected at rendering of services unless other arrangements have been made. I hereby also consent to medical treatment for my present condition or injury. and for any illness or injury incurred at any time after the date noted below. I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient. authorized to furnish the information requested.I understand that even if I have some type of insurance coverage. I am responsible for payment of services.
Signature of Responsible Party (relationship)

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Date

MonthDayYear
Date
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Authorization to Release Medical Records
I, the undersigned, authorize the release of, or request access to ALL the medical records of the above named patient. The information is needed for continuity of care.

The medical records may be released to Marta Long MD by Fax 949-682-0893.

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected. I understand that the specified information to be relased may include but is not limited to history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including HIV and AIDS. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. The authorization will expire six months from the date of my signature, unless I revoke the authorization prior to that time.
Name of Physician or Clinic. To whom may we address the request for your medical records?

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

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Your Pharmacy & Medications

Where would you like prescriptions sent to? In lieu of completing the medication list, bring your pill bottles at your first appointment. Include all prescription medications (pills, patches, injections), supplements, vitamins, and herbs.
Pharmacy Name
Pharmacy Address
Pharmacy Phone
Pharmacy Fax
Allergies*
List your allergies and reactions. NONE, if no known allergies.
You may upload a screenshot of your medication bottles (labels) with name of medication, how much and how often you take, or complete the list below.

Browse Files

Cancelof
Medication#1
Generic and/or Brand Name
Strength/Dose
Use units such as mg, IU, mL,
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#2
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#3
Strength/Dose
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#4
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#5
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#6
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#7
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#8
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#9
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
Medication#10
Generic and/or Brand Name
Strength/Dose
How many mg? IU? mL? units?
How often do you take?
In the morning (AM), Once a day (DAILY), Twice a day (TWICE), At bedtime, etc
When did you begin taking?
Month/Day/Year
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Consent

Please read and sign the following PDFs. A copy of each will be emailed to you.
Privacy Policy
California Medical Board Notifications
Consent for Telemed
I have received and read, or declined to read, the Privacy Policy and the California Medical Board notifications; I have read the Consent for Telemedicine, and I give Consent.
Signature

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After you click on Submit, you've completed all the pre-visit paperwork, and you're all set. Only two more items remain: One, the date and time of your appointment. Second, the payment to reserve your appointment. Please call to schedule your house call 949-237-2949; after reserving your appointment time, you'll receive a payment link in order to confirm your apointment. Thank you.
Should be Empty:

Patient Agreement

Patient Information Sheet

Authorization to Release Medical Records

Your Pharmacy & Medications

Consent