Patient Registration Form

Online Patient Registration

You may preregister with our office by filling out our secure Online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to send us your information. On your first visit to our office, we will have your completed form available for your signature.

After you have submitted your form, you will have the opportunity to securely upload and transmit images of your insurance card.

Clickable button to launch secure, online Patient Registration form and system

The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Patient Forms in English and Spanish

If you have any questions, please call our office at Santa Barbara: Santa Barbara Office Phone Number 805-682-0933 or Lompoc: Lompoc Office Phone Number 805-735-3665.

Forms in English

You may preregister with our office by downloading and filling out our PDF Patient Registration and Notice of Privacy Form. After you have completed the form, please make sure to bring it into the office on your next visit.

Formas en Español

Usted puede pre-inscribirse con nuestra oficina descargando y rellenando nuestro Registro de Pacientes y Notificación de Privacidad PDF. Después de haber completado el formulario, por favor, asegúrese de llevar a la oficina en su próxima visita.

Technical Note:

You will need Adobe Acrobat Reader to use our forms. You may download Acrobat Reader free from Adobe’s web site if it is not already installed on your system.