New Patient Registration

New Patient Registration

Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information

This information will be sent to your provider and will be kept as a part of your child's patient record.
First Name*
Last Name*
Email address*
example@example.com
Mobile phone number *
Date of Birth *

MonthDayYear
Child's Gender*

MaleFemale
Name of Primary Caregiver (i.e. name of parent on insurance card)*
Relationship of Primary Caregiver to Child *
DOB of primary caregiver (i.e. mom, dad)*

MonthDayYear
Date
Best Phone Number of Primary Caregiver *
Please enter a valid phone number.
Name of Secondary Caregiver *
Birthday of Secondary Caregiver *

MonthDayYear
Date
Relationship of Secondary Caregiver to Child *
Phone Number of Secondary Caregiver*
Please enter a valid phone number.
Type of Insurance*

Anthem Blue CrossLA CareHealth NetStraight Medi-CalHMOPPOSelf Pay
Short TextCIN# or Identification Number or Subscriber ID*
PCP Name listed on your insurance card (if you have Medi-Cal or HMO)*

Dr. Eva ChanDr. Jackyln Chan
Preferred Language*

EnglishChineseSpanishTagalog
Street Address *
City *
Zip Code *
Preferred Date (NO SATURDAY REQUESTS PLEASE) *

MonthDayYear
Date
Preferred Time of Day (choose multiple)*

MorningAfternoon
Upload a photo of your insurance card *

Image should be between 0*0 and 4920*4920
Cancelof
Upload your child's immunization card/yellow card (front and back)*

Image should be between 0*0 and 4920*4920
Cancelof
Please upload parent(s)/guardian(s)' ID or driver licenses here- if there are two parents, please upload both of them *

Cancelof
Upload any additional files here *

Image should be between 0*0 and 4920*4920
Cancelof
How did you hear about us?*

Friends/familyGoogleHealth PlanIPAOther
Should be Empty:

New Patient Registration

Patient Information