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.