New Patient Forms

We’re thrilled that you’ve chosen to partner with us for your skin care. We ask that all new patients please complete and return the new patient paperwork prior to visiting our office.

You can download the documents here or fill in the online form below.

We’ll have a few forms for you to sign once you get to our office. Additionally, we ask new patients to also submit copies of the front and back of both their ID and insurance card(s).

All required documents can be emailed to info@bitabagherimd.com. If you do not have access to email, your paperwork can be faxed to (949) 236-7900.

      • new patient paperwork
      • copy of ID
      • copy of insurance cards
Dr. Bita Bagheri's new patient forms

Dr. Bita Bagheri's new patient forms

PERSONAL INFO

First
Last
Address
Address
City
State/Province
Zip/Postal
Employment
How did you hear about us?

MEDICAL HISTORY

First
First
First
Prior history of melanoma?
Prior history of skin cancer?
Prior history of Basal Cell Carcinoma?
Prior history of Squamous Cell Carcinoma?
Prior history of unknown type skin cancer?
Does your family have a history of malignant melanoma?
Have you ever had moles removed that were described as atypical?
I'm on blood thinners

ALLERGIES

Allergic to Adhesives?
Allergic to Latex?
Allergic to Lidocaine?

LIFESTYLE

I use sunscreen regularly
I use tanning beds regularly
Smoking?
Drinking?

HOW CAN WE HELP?

Is this condition causing weight loss?
Is this condition causing fever?
Is this condition affecting your general health?
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