Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
"Doctors Dagli (husband and wife) have always provided top care in the 10+ years I have been going there. Dr. Hakan Dagli has been more than a primary care physician during this time and has saved me from unnecessary shoulder surgery by examining the shoulder in a relaxed, thorough, and unhurried manner. I highly recommend this team."
Pantops Family Medicine Forms
High School Sports Physical Forms. The parent section must be filled out prior to the visit.
Preschool and Kindergarten Entrance Forms. The parent section must be filled out prior to the visit.
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)