Patient Forms at El Camino Women’s Medical Group
We are happy to provide forms online so that our patients may print them and fill them out at their convenience. This will save you time, particularly during your first visit to our practice.
First Visit
Please fill out both the Patient Registration and Medical History Form for your first visit. You can review our Privacy Practices here as well. Once you arrive at the office, we will ask you to sign the Consent for Treatment and Acknowledgement of Receipt.
- Patient Registration
- Medical History
- Privacy Practices
- Telemedicine consent
- Consents for Treatment (to be signed electronically at check in)
- Health Exchange Consent
- EHR Handout
- Release of Information
- Release of information to patient or other provider
Insurance or Address Change
If you have a new insurance plan or provider, or if you have moved to a new address, please fill out the patient registration form below. You may fax it to the office, email it to moc.n1685303394emowo1685303394nimac1685303394le@of1685303394ni1685303394, or bring it with you to your next appointment.
Release of Information
In order for us to access pertinent medical information you may have with another healthcare provider, you will need to fill out this form. You can fax or email the form to us at moc.n1685303394emowo1685303394nimac1685303394le@of1685303394ni1685303394, or bring it with you to your next appointment.
You always have a right to a copy of your medical records. Please give us seven to ten days’ notice, and we will send a copy of your medical records to any physician you wish. We can also prepare a copy of your records for pick-up by you personally.
Any release of records, even to yourself, requires your written authorization. To provide this authorization, please complete the Release of Information form below.
For questions, please feel free to contact El Camino Women’s Medical Group at (650) 396-8110 or moc.n1685303394emowo1685303394nimac1685303394le@of1685303394ni1685303394.