2018 Patient Registration Form


Online Patient Registration is temporarily unavailable. You can obtain the form by downloading it; by calling us to have it mailed to you; or by visiting our offices in-person to pick up an application.
I want to download the
Patient Application form (.pdf)
I want to have a Patient Application Form
mailed to me.
Call our office at (760) 342-4414 to
request a mailed application.
I want to pick up a
Patient Application Form
Visit our office at 82915 Avenue 48
in Indio
to pick up an application.
Once your application is completed and you have gathered verification of eligibility, call or stop by our office to schedule an appointment. Call our office at (760) 342-4414 for any questions you may have.