New Patient Registration
Complete this before your appointment and your provider can be better prepared during their time with you.
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
*
-
Month
-
Day
Year
Child's Gender
*
Male
Female
Other
Child's Mother's Maiden Name
*
First Name
Last Name
Name of Primary Caregiver (i.e. name of parent on insurance card)
*
DOB of Primary Caregiver (i.e. mom, dad)
*
-
Month
-
Day
Year
Date
Relationship of Primary Caregiver to Child
*
Best Phone Number of Primary Caregiver
*
Please enter a valid phone number.
Email address of Primary Caregiver
*
example@example.com
Name of Emergency Contact
*
DOB of Emergency Contact
*
-
Month
-
Day
Year
Date
Relationship of Emergency Contact to Child
*
Phone Number of Emergency Contact
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Insurance
*
Anthem Blue Cross
LA Care
Health Net
Blue Shield Promise
Straight Medi-Cal
HMO
PPO
Self Pay
Insurance/Subscriber ID#
*
PCP Name listed on your insurance card (if you have Medi-Cal or HMO)
*
Dr. Eva Chan
Dr. Jackyln Chan
Preferred Language
*
English
Chinese
Spanish
Tagalog
Preferred Date (NO SATURDAY REQUESTS PLEASE)
*
-
Month
-
Day
Year
Date
Preferred Time of Day
*
Morning
Afternoon
Any
Upload a photo of your insurance card (FRONT)
*
Browse Files
Drag and drop files here
Choose a file
Image should be between 0*0 and 4920*4920
Cancel
of
Upload a photo of your insurance card (BACK)
*
Browse Files
Drag and drop files here
Choose a file
Image should be between 0*0 and 4920*4920
Cancel
of
Upload your child's immunization card/yellow card (FRONT)
*
Browse Files
Drag and drop files here
Choose a file
Image should be between 0*0 and 4920*4920
Cancel
of
Upload your child's immunization card/yellow card (BACK)
*
Browse Files
Drag and drop files here
Choose a file
Image should be between 0*0 and 4920*4920
Cancel
of
Please upload parent(s)/guardian(s)' ID or driver licenses here- if there are two parents, please upload both of them
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload parent(s)/guardian(s)' ID or driver licenses here- if there are two parents, please upload both of them
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload any additional files here
Browse Files
Drag and drop files here
Choose a file
Image should be between 0*0 and 4920*4920
Cancel
of
How did you hear about us?
*
Friends/family
Google
Health Plan
IPA
Other
Submit
Mobile phone number
*
City
*
Street Address
*
Zip Code
*
Should be Empty: