Forms

Please fill form 1 and 2 below in the language you are most comfortable with and bring them with you when you come to visit us. (You
may also fax the forms to us.)

1.  
Patient Registration Form:

English
Spanish
Chinese

2.  Child Health History Form:

English
Spanish
Chinese

3.  Consent to Treat Minor in Absence of Parent /Guardian

English
Spanish
Chinese


We will present the documents below in the office when you come:

4.        Notice of Private Practice
5.        Pediatric Patient Bill of Right
6.        California Minors Consent Law



                     
 The website and clinic are HIPAA compliant
Welcome to
Pediatric Clinic de Chino Hills --- Kids' Medical Home