Make sure you have called to schedule an appointment! (949) 706-1212 Please fill out lab forms (below) prior to your visit: New Client Form Name First Last Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason-for-visit(Required)Is the patient the financially responsible party? Please upload ID bellow in fileYesNoIf No, please list the name:FileMax. file size: 100 MB.(Registration Form, Lab Forms, Insurance Card, etc.)Signature: Type Name *(Required)A 3.5% customer service charge is applied to all major credit card transactions. The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Bar to release any information required to process my claims. I hereby voluntarily consent to the rendering of care, including treatment, performance of diagnostic and/or medical procedure.How did you hear about us? *(Required) Google Yelp Next Door Family Friend Other Δ Call to Schedule (949) 706-1212 Connect With Us On Social Media Facebook Google LinkedIn YouTube Instagram Yelp 365 Days of Doctor House Calls and Urgent Care House Calls House call doctor, Dr. Iman Bar, is bringing urgent care to you! Call to schedule same day medical visits in the comfort of your own home near Newport Beach. Share this:BlueskyPostThreadsMastodonNextdoorRedditPrintMorePocketShare on TumblrTelegramWhatsAppEmailLike this:Like Loading...
