NEW CLIENT FORM

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

Name

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Reason-for-visit(Required)

Is the patient the financially responsible party? Please upload ID bellow in file

If No, please list the name:

File

Max. file size: 32 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)