SAFE and SECURE Online Submission
For your convenience, the following forms may be submitted online prior* to your first appointment and transmitted SAFELY and SECURELY to our Patient Registration Desk. To complete the form simply click on the link below:
Adult Registration Packet – ONLINE SUBMISSION
Pediatric Registration Packet – ONLINE SUBMISSION
*To ensure optimum service, we recommended you complete your registration at least 2 days prior to your appointment. For technical support for submitting registration forms online, please contact the Graybill Marketing Department at 760-291-6909.
Paper Submission
Flu Vaccine Consent 2020
CDC Flu Vaccine Information Statement
Adult Registration Packet (.pdf 1MB)
Pediatric Registration Packet (.pdf, 751 KB)
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)