Escondido – New patient registration Please enable JavaScript in your browser to complete this form.NAME *FirstMiddleLastDOB *date of birthSEX *MFEMAIL *For Appointment Reminder & Healthcare InformationADDRESS *Address Line 1Address Line 2CityCAAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePRIMARY PHONE NUMBER *main number to contact you such as a cell phone I AUTHORIZE LAS PALMAS MEDICAL GROUP *I AUTHORIZE LAS PALMAS MEDICAL GROUP TO LEAVE MESSAGES IN REGARDS TO MY APPOINTMENTS AT THE ABOVE PHONE NUMBERIN CASE OF AN EMERGENCY, NOTIFY: *FirstLastEMERGENCY CONTACT PHONE NUMBER *Relationship of emergency contact *SpouceParentSiblingOtherEmergency contact addressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeINTERPRETER NEEDED? *YESNOWas advance directive offered *YesNoHOW DID YOU HEAR ABOUT US?FAMILY/FRIENDYELPFACEBOOKGOOGLEINSURANCE PROVIDERCONSENT FOR TREATMENT -ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE MEDICAL RECORDS *-I hereby consent and authorize the administration of all emergency diagnostic and therapeutic treatment for me or my minor child that may be necessary in the judgement of the attending physician. I hereby authorize the above named Medical Group and Laboratory to furnish information concerning this illness and I authorize and instruct these same insurance carriers to make payment directly to the above mentioned Medical Group and Laboratory for medical expense benefits (Inc, major medical benefits) otherwise payable to me. A photostatic copy of this assignment and authorization shall be considered as effective and valid as the original. This lien is irrevocable. I also understand that I'm financially responsible to the above named Medical Group and Laboratory for charges not covered and paid by the insurance carrier.Date: *Submit