Important Forms

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PATIENT REGISTRATION PACKETS

Please complete your Registration Packet at least 2 days prior to your first appointment to ensure optimum service. Your information will be transmitted SAFELY and SECURELY to our Patient Registration Desk. To begin filling out the Packet, click one of the links below:

Adult Registration Packet – ONLINE SUBMISSION
Pediatric Registration Packet – ONLINE SUBMISSION

For technical support for online forms submission, please contact the Graybill Marketing Department at 760-291-6909.

OTHER FORMS

For paper submission, please download, print, and complete the appropriate form(s), then bring a copy with you to your appointment.

Flu Vaccine Consent 2020
CDC Flu Vaccine Information Statement

Adult Registration Packet (.pdf 1MB; Note: this is the paper version of the registration packet; to complete the Packet online click the link at the top of this page.)
Pediatric Registration Packet (.pdf, 751 KB. Note: this is the paper version of the registration packet; to complete the Packet online click the link at the top of this page.)
Patient Financial Agreement – English (.pdf, 169 KB)
Routine Preventive Exam – English Spanish (.pdf, 193 KB)
Notice of Privacy Practices (.pdf, 96 KB)
Acknowledgement of Receipt of Notice of Privacy Practices (.pdf, 106 KB)
Permission to Discuss PHI (.pdf, 282 KB)
Medical Records Release to Graybill (.pdf, 386 KB)
Medical Records Release to Other Provider(.pdf, 174 KB)
NextGen Patient Proxy – English Spanish
Preparticipation Physical Exam – History (.pdf, 148 KB)

Formas De La Lengua Espanola

Formulario de administracion de la vacuna contra la influenza 2020
CDC Declaracion de informacion sobre la vacuna contra la infuenza

Registro del Paciente Adulto (.pdf 2.2 MB)
Registro del Paciente Pediátrico(.pdf, 751 KB)
Exámenes Preventivos de Rutina (.pdf, 193 KB)
Acuerdo Financiero del Paciente (.pdf, 170 KB)
Aviso de Prácticas de Privacidad 0415 (.pdf, 165 KB)
Autorización Para Revelar El Registro Médico (.pdf, 1MB)
Autorización Para Revelar El Registro Medico al Otro Proveedor (.pdf, 1MB)
Los Padres/Tutor Legal Para Acceder a Peticiondel Paciente Menor NextGen Cuenta de Portal (.pdf, 540 KB)

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