Medical History Form

In Preparation for Your Appointment

To make the most of your appointment time, please download, print and complete the attached Medical History Form and return it to us at least three business days prior to your scheduled appointment. You can do this in one of two ways:

By FAX

Regardless of whether you will be seen in our Fremont or Menlo Park Clinic, you may fax your completed form to our secure fax at 510-793-4318.

-OR-

By EMAIL

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

Patient Medical History Form

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