Name *
Name of Patient *
Email *
Phone *
Preferred Appointment Date *
Preferred Appointment Time *
Best time to reach you
Insurance Name
Insurance Phone No.
Insurance Subscriber
Subscriber Date of Birth
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If you prefer, please provide us with the following information. We will try to accommodate your request. We will contact you to confirm the appointment. Please complete the form to the left or please call 909-880-1600 for an appointment.


If you prefer, also, please print registration forms (see below) and complete it at your home at your convenient time. Please bring those with you at the appointment.


Download Forms


 Patient Questionnaire

 Financial Insurance

 Health History

San Bernardino office


Business Hours

Monday         5:00 PM - 8:30 PM*

Tuesday        Reception - 9:30 AM - 6:30 PM*

Wednesday   5:00 PM - 8:30 PM*

Thursday      Reception - 9:30 AM - 6:30 PM*

Friday           8:00 AM - 7:00 PM*

Saturday       8:00 AM - 5:00 PM*

Sunday         8:00 AM - 2:00 PM

*Schedule varies as needed.