Patient Forms/Medical Records
To expedite your check in process, we encourage you to fill out your health information through the patient portal before your appointment.
Please print form that corresponds to your visit, make sure to fill out completely and bring you to your appointment.
Pregnant Patient Form
Please complete medical information via the patient portal as well as download the OB Questionnaire form.
In order to prepare for your mammogram visit, we encourage you to complete the medical release from and email or fax to: firstname.lastname@example.org or 949.829.0965. Please select the following location of your prior mammogram below.
You are entitled to copies of your medical records, whether for yourself or another medical provider. You will need to sign a medical records release authorization, which you may fax, email or drop off to our office.
Medical Records Release Form
We strive to fulfill your request in a timely manner, please allow 10 business days for your request to be processed. There will be a $15.00 fee for the release of more than 10 pages / No Fee for records that are released to an MD's office or Hospital.
** Please note that unencrypted e-mail sent over the Internet is not secure and may not remain confidential; thus, any information sent by email is sent at the sender's own risk. We encourage the use of a fax instead.
For submission of your medical records to our practice, we ask that you please either fax, mail, or hand carry them in. We do not accept CDs.
Your Privacy is important to us. We make it a priority to keep your records confidential.
Phone: 949.829.5500 ext. 616