Call 310.205.3555 to Schedule an Appointment

Welcome to my practice and thank you for allowing us to take care of your dermatological needs.

 

Here are the instructions:

• Please complete the registration packet below
• Click on each link to open the form in a new window
• Complete the form online, sign where necessary, and print
• Bring all of these forms with you to the appointment, or EMAIL them to This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or FAX them to 310.205.3553

 

These forms are saved in PDF format and require Adobe Acrobat Reader. If you don’t have Acrobat Reader, please

Click Here to Download

Patient Questionnaire

Health Information Portability and Accountability Act (HIPAA)

Medical Photography Consent

Financial Policies

Authorization to Release Information and Assignment of Benefits

Arbitration Agreement

Please remember to bring the following items to your appointment:

• Identification (Driver’s License or ID Card)
• Insurance Card
• Completed and Signed Patient Registration Forms (above)

For patients who would like to EMAIL their forms prior to their appointment for quicker service, please do the following:

• Save the forms to your desktop or saved folder
• Send the forms as attachments to This e-mail address is being protected from spambots. You need JavaScript enabled to view it
• IDs and insurance cards can be faxed to 310.205.3553