New Patient Intake Form
In Baldwin Park and the San Gabriel Valley
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Complete your intake form at least 72 business hours before your first visit so we can verify your coverage.
This form is for patients who have already made initial contact with our team.
If you have not made contact, please call our office at (626) 960-3741 prior to filling out the form below.
Three simple steps
Have these ready
- Your insurance card
- Your date of birth and member ID
- A list of your current medications
Complete the form
Fill out the secure online form below at least 72 business hours before your visit. All new patients must submit it before coming in.
We verify your coverage
Our insurance team reviews your benefits and lets you know your expected copay before your visit.
New patient intake form
If you do not have a tentative appointment, please call our office at (626) 960-3741 prior to filling out the form below.
Having trouble with the form? Open it in a new window, download the printable form, or call or text us at (626) 960-3741.
Why we ask for this in advance
We understand that providing this information before your visit can take some effort, and we appreciate it. Having accurate information ahead of time lets us streamline your visit. Our office prioritizes financial transparency, and your information allows our insurance team to tell you about the upfront copays set by your health plan.
The information you provide is confidential and used for internal purposes only. Read our Notice of Privacy Practices.
Thank you, and we look forward to welcoming you to our eye care family.
Let’s take care of your eyes
Call, text or request an appointment online. We verify your insurance before your visit.
3000 Big Dalton Ave, Baldwin Park, CA 91706 · Monday to Friday, 8am to 5pm, and some Saturdays