John La Puma, M.D. Registration Page 1
The Santa Barbara Institute for Medical Nutrition & Healthy Weight
Let Food Be Your Medicine Too!
Registration
Patient Name _________________________________________________ Date of Birth ________________
Mailing Address_________________________________________Social Security #____________________
Home Phone ___________________ Business Phone __________________ FAX ___________________
E-mail Address_________________________________________________
Referred By_______________________________________________________________
Address__________________________________________________________________
City _____________________________________State_____ Zip____________________
Phone ____________________ E-Mail Address_________________________________
Do you belong to an HMO or have Medicare? Yes ___ No ___
If yes, do you understand that you will have to pay out of pocket for all expenses generated by our office? Yes ___ No
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List your doctors and their specialties - use additional sheet if necessary :
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List your current medications and supplements - use additional sheet if necessary:
____________________________________________________________
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The information I have provided above is true and correct to the best of my recollection.
Signature: ______________________________ Date:________________Printed Name: ______________________________
Thank you for you interest in my medical practice. Please return this with the other forms to the receptionist. Do not fax or mail.
John La Puma, MD, FACP
Medical Director
Board Certified, Internal Medicine
Medical Office and Appointments: 2403 Castillo Street, Suite 205 Santa Barbara CA USA 93105
805-569-7827voice 805-569-7828fax
www.DrJohnLaPuma.com
www.PediatricObesity.com
