NEW CLIENT FORM

Please call to schedule an appointment at (949) 706-1212

Name *

First

Last

Date of Birth *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Visit *

Emergency Contact Info

Emergency Contact Name

Emergency Contact #

Relationship

Is the patient the financially responsible party?

If No, please list the name:

Insurance Info

Company Name

Insurance ID

Group #

Insurance Phone #

Insurance Address

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

(Registration Form, Lab Forms, Insurance Card, etc.)

Confirmation

Signature: Type Name *

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.

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