Forms

 

Below you will find a registration form for your updated health information as needed. If you should have any questions regarding this form, please send Diana an email with your concerns. I will respond in a timely manner and answer any questions you may have.

You will need Adobe Reader to download the forms. The link below will take you to the site necessary to access the plug-in necessary to download forms.

pdf icon Get Adobe Reader

Click for Patient Registration Form

Click for Authorization Form

Contact & License Information

 

P.O. Box 264 | San Juan Bautista, CA 95045-0264 | Ph: 831.623.4585 |
Fax: 831.623.4350

RDHAP License No.

Calif. Lic #HAP00135

If you should have any questions, please don't hesitate to contact Diana Carr, RDHAP directly.

You may also contact me via email at: Smiles by Diana