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8:00 AM - 4:30 PM

(Mon-Fri)

951-506-0400


Registration

Tell Us Your Chief Complaint

  Please select one or more boxes below to describe the reason you are visiting us:  
  Facial  
  Nose & Sinuses  
  Throat & Neck  
  Mouth  
  Ears  
 
Comments
Please describe your chief complaint and any associated issues
 
     
 
Allergies or Bad Reactions to Medicines
 
    Penicillin Sulfa  
    Tetracycline Keflex  
    Cipro No known drug allergies  
   
If your allergy is not listed above, please enter it below.
 
     
 

Medications

Nasal Sprays Antibiotics  
    Blood Pressure Medications Asprin  
    Coumadin Plavix  
    If you are taking medication not listed above please enter below.
Please include Medication Name, Dosage, How many times a day.
 
     
 
Pharmacy
     
    Name City and Cross Street  
 
1.
 
 
2.
 
 
3.
 
         
New Patient Registration
Every attempt will be made to schedule your next appointment on the date
and time specified below. We will contact you within 24 hours to confirm
and/or suggest a new appointment date and time.

We are open from 8:00 - 4:30 PM Monday - Friday
Date Request
e.g. dd/mm/yyyy
Time Request
e.g. 10:00 AM
     
Last Name
Middle Initial
First Name
   
Address
SSN
Suite / Apt. #
State
City
Zip
Home Phone
e.g. 9515262044
Cell Phone
Work Phone
Email
Date of Birth
Age
Gender
Male Female  
Marital Status
 
Employer
Phone
Emergency Contact
Contact
Phone
Relation to Patient
   
Referring Physician
Doctor's Name
Phone
Responsible Party
Same as Patient Information
Please provide the person's name whom is responsible for this Account.
Last Name
Middle Initial
First Name
   
Patient's relation to
Responsible Party
   
Address
   
Suite / Apt. #
State
City
Zip
Home Phone
Work Phone
Primary Insurance Information
Same as Patient Information  Same as Responsible Party Information
Please provide the person's name who is the Primary Insurance Holder.
Last Name
Middle Initial
First Name
Date of Birth
Patient's relation to
Insured
SSN
Personal Address
   
Suite / Apt. #
State
City
Zip
Home Phone
Cell Phone
Employer
Phone
Insurance Company
Plan Type
Insurance Address
   
  Enter address as seen on your insurance card.
Subscriber ID
Group #
Co-Pay Amount
   
Secondary Insurance Information
Please provide the person's name who is the Secondary Insurance Holder.
Last Name
Middle Initial
First Name
Date of Birth
Patient's relation to
Insured
SSN
Personal Address
   
Suite / Apt. #
State
City
Zip
Home Phone
Work Phone
Insurance Company
   
Insurance Address
   
  Enter address as seen on your insurance card.
Subscriber ID
Group #

HIPAA PRIVACY RULE

CONSENT, INFORMATION DISCLOSURE, AND INSURANCE AUTHORIZATION
All information provided by the patient is deemed private under the Health Insurance Portability and Accountability Act (HIPAA)
and will be used as follows only with patient consent.  I hereby authorize Ruiz Ent. to furnish information to other providers, health care treatment facilities, and my insurance companies for purposes of treatment, payment, and health care operations.  I hereby assign to the physician all payments for medical services rendered to myself and/or my dependents.  I understand that I am responsible for any amount not covered by insurance.






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