New Patient
Let us know who you are and your interest in Hill Park so we can help schedule a visit that will meet your needs.
Email address *
Phone Number *
Your answer
Preferred Form of Communication *
Required
Patient's First Name *
Your answer
Patient's Last Name *
Your answer
Is there another name you prefer to go by?
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Point of contact? *
Guardian/Parent Name (if applicable)
Your answer
Which practitioner would you like to see? *
Required
Billing Address *
Your answer
Mailing Address same as billing?
Mailing Address
Your answer
Reason for Visit *
Your answer
How did you hear about us?
Your answer
Our Intake Process is Digital!
You'll get an email from our online patient portal called ChARM. Once you have an account set up with ChARM, you'll receive a list of questionnaires to fill out; these make up our intake paperwork.
With ChARM online, you'll be able to see your charts, labs, treatment plans, and message our office securely and safely.
If you do not wish to sign up for ChARM, please let our staff know so they can mail out a hardcopy or email a copy of our new patient packet.
Office Policies
Payment
Full payment is due at time of service.

Insurance
We do not accept any form of insurance (including Medicare and Medi-Cal). At each appointment, you will be provided with a superbill that you may submit to your insurance company for reimbursement.

Cancellation
If it is necessary to cancel your scheduled appointment, we require that you call at least two business days in advance. Calling earlier is greatly appreciated. There are no fees associated with appointments that are cancelled or rescheduled with two business days’ notice.

Late Cancellation/Missed Appointment
If you cancel an appointment with less than two business days’ notice, miss an appointment entirely, or miss an appointment by arriving more than fifteen minutes after the scheduled appointment time, the following fees apply:
For the first late cancellation or missed appointment, you will be responsible for one-half of your scheduled appointment fee. For all subsequent missed appointments, you will be responsible for the full cost of your scheduled appointment.
Payment for missed appointments is due before your next scheduled appointment. If you have not paid prior to your next visit, please be prepared to pay your outstanding balance at the time of your appointment.

Phone Appointments
Phone appointments are charged at the same rate as office visits. When scheduling a phone appointment, please be prepared to provide us with your credit card number. This card will be charged directly following your appointment. Please note that phone appointments may not be billed as office visits and therefore are not reimbursed by insurance.

Emergency & After-Hours Service
Our practitioners do not provide emergency care, which means they are only available during their normal office hours. We suggest you maintain a relationship with a primary care provider who provides emergency medical services in the event that you may require such services.

Letters, Reports, and Forms
Our practitioners will prepare any necessary documentation at your request, for a fee based on the time spent in their preparation.

Confidentiality
Your records and all personal information are kept in strictest confidence. No personal or medical information is released from our office without your prior authorization.

Fragrance-Free Environment
Please refrain from wearing any type of perfume, cologne, essential oils, after-shave, or scented hair or body products into the office. We appreciate your courtesy toward those who suffer from sensitivities and allergic reactions to fragrances.

Acknowledgement and Agreement *
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