Pre-Registration Page 1: Patient Information

Pre-Registration

If you need help or have a question, please call (925) 941-3030.

Steps: 1 Patient Information 2 Payment Details 3 Service Information 4 Review

Appointment Details

Note: This is not a request for a new appointment. Maternity patients do not need to enter an appointment date or time.

Service Location*

Appointment Date*

Time (Hour:Min)*

Patient's Full Legal Name

First*

Middle

Last*

Suffix

Maiden Name

Contact Information

Phone* Check the boxes below if we may leave messages at this number

Home

Cell

Work

Communication Preferences

Out of the following, please rank how you would prefer we contact you from your most (top) to least (bottom) favorite. Drag items up and down or use the arrows to put them in order.

Home Address

Address 1*

Address 2

City*

State*

ZIP Code*

Country

May we send mail to this address?* Yes No

Mailing Address

Address1*

Address2

City*

State*

ZIP Code*

Country

Additional Patient Information

Gender*

Male Female

Date Of Birth*

Last 4 digits of Social Security Number*

Marital Status*

We ask you to tell us your race, ethnicity and preferred language so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care. This information will only be used for performance improvement and the confidentiality of what you say is protected by the law.

Hispanic or Latino Origin*

Race*

African-American/Black - A person having origins in any of the black racial groups of Africa.
Asian - A person having origins in any of the Far East, Southeast Asia, or the Indian subcontinent.
Pacific Islander/Hawaiian - A person having origins in any of the original peoples of Polynesian, Micronesian, Melanesian or other Pacific Islands.
Caucasian/White - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
Native American/Eskimo/Aleut - Native people from North America who maintain tribal affiliation or community attachment.
Bi/Multi-racial - A person who identifies with more than one race.
Other - A person who does not identify with the above race categories.

Preferred Language*

Religious Preference*

Employment Status*

Retirement Date

Emergency Contact

First Name*

Last Name*

Home Phone

Please enter a home or cell phone number*

Cell Phone

Please enter a home or cell phone number*

Relationship To Patient*