Patient Registration & Consent Forms

We would like to make your visit as efficient as we can. If you would like to fill out your patient registration information before you come in, please visit the links below to print the appropriate forms, fill them out in English or Spanish, and bring them with you to your appointment.*

If you have questions or need assistance, please call our Pre-Registration Department at (805) 681-1840.

Registration Forms For Adults >
Registration Forms for Minor Patients >
Registration Forms for Seniors >
Additional Consent and Authorization Forms >
Radiology Patient Forms >

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For Adults

Health Questionnaire >

Health Questionnaire (Español) >

General Consent for Medical Treatment >

General Consent for Medical Treatment (Español) >

Patient Registration/Financial Policy >

Patient Registration/Financial Policy (Español) >

  
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For Minors

Pediatric Health History >

Pediatric Health History (Español) - Coming Soon

General Consent for Medical Treatment >

General Consent for Medical Treatment (Español) >

Patient Registration/Financial Policy >

Patient Registration/Financial Policy (Español) >

Authorization for Agent to Consent to Medical Treatment of a Minor >
  
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For Seniors

Health Questionnaire >

Health Questionnaire (Español) >

General Consent for Medical Treatment >

General Consent for Medical Treatment (Español) >

Patient Registration/Financial Policy >

Patient Registration/Financial Policy (Español) >

*Submitting preliminary healthcare or insurance information or making an appointment with the practice does not establish a physician-patient relationship. That relationship is not created until the office visit has been completed.
  
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Additional Consent and Authorization Forms

There are circumstances when a patient may want someone else to be able to obtain or provide medical or financial information on their behalf. In keeping with HIPAA (Health Insurance Portability and Accountability Act) privacy and security requirements, special consents and authorizations are available at Registration for your convenience, or you may download them below and bring the completed forms with you when you arrive for your appointment.

Here are some additional forms that may apply to you. Click here to learn more about these forms >

Authorization for Agent to Consent to Medical Treatment of a Minor >

Consent to Disclose Protected Health Information to a Designated Patient Representative >

Consent to Disclose Protected Health Information to a Designated Patient Representative (Español) >

Patient Consent for Release of Billing Information >

Request for Proxy Access to MyChart**

Authorization to Release Radiologic Records >

Outside Records Routing Slip >

Sansum Clinic: Authorization for Use/Disclosure of Protected Health Information > (English)
Cancer Center: Authorization for Use/Disclosure of Protected Health Information > (English)
Sansum Clinic: Authorization for Use/Disclosure of Protected Health Information > (Español)

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Radiology Forms

If your visit includes an MRI/MRA or CT Scan in our Radiology Department, please visit this page to access the questionnaires and consent forms for that department.

Radiology Forms >

Authorization to Release Radiologic Records >

*Submitting preliminary healthcare or insurance information or making an appointment with the practice does not establish a physician-patient relationship. That relationship is not created until the office visit has been completed.

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