30110 Crown Valley, Suite 101
Laguna Niguel, CA 92677

Tel: 949.363.5322
Fax: 949.363.5326

Patient Forms

New Patient Forms

Please fill out, print and bring completed forms on your first visit to our office.

Medical Records Release Authorization Forms

The following are provided to authorize the release of your medical records. From the options below, please print the appropriate form, fill out, and fax to the recipient indicated:

To have records SENT TO Family Medical Center (These are records originating from another doctor or medical facility).
Authorization_SENT_TO_FMC Fax completed form to the provider.

To have records SENT FROM Family Medical Center (These are records going to another doctor, or to the patient). Please be aware there is a fee to provide patients with a copy of their medical records.
Authorization_SENT_FROM_FMC Fax completed form to Family Medical Center.

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