Medical History Form

In Preparation for Your Appointment

Once you have scheduled your initial office visit, and at least three days before your appointment, please fill out the secure online Medical History Form below (remember to hit “submit” at the end). The form will be immediately and securely transmitted to our staff—this is our preferred method of receiving this information from you.

Online Patient Medical History Form

Alternately, you may submit our printable version (below) by FAX or email.

By FAX

At least five business days before your appointment, please download, print, and complete the Medical History Form and return it to us.

If you will be seen in our Fremont Clinic, fax your completed form to 510.793.4318.

If you will be seen in our Menlo Park Clinic, fax your completed form to 650.325.2019.

-OR-

By EMAIL

  • If your appointment is in our Fremont Clinic, scan and email your completed form to Vanessa Binag at Vanessa@DearbornAssoc.com.
  • If your appointment is in our Menlo Park Clinic, scan and email your completed form to Dejanae Hall at Dejanae@DearbornAssoc.com.

Printable Patient Medical History Form (PDF)

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