Hercules, CA 94547
(510) 724-4435
Berkeley, CA 94705
(510) 204-0965
These forms are available electronically as part of the self-check in process on the patient portal. You may also download all forms in this PDF packet. If you would like paper copies mailed to you, please contact the office to have a packet in English or Spanish mailed to you. Please bring all four (4) completed forms with you to your appointment.
Below are links to download our office’s records release forms. Records release forms are required for our office to both release patients’ records and to obtain patients’ records from another provider. These forms must be signed by the patient and returned to our office prior to the records being released or obtained. Please be as specific as possible as to what records are being requested when filling out the form. Also note that our office does charge a $25 fee for the copying of records up to the first 10 pages; An additional fee of 25 cents applies to each additional page thereafter.
500 Alfred Nobel Dr., Suite 200
Hercules, CA 94547
Phone: (510) 724-4435
Fax: (510) 724-4686
Map & Directions
2999 Regent St., Suite 201
Berkeley, CA 94705
Phone: (510) 204-0965
Fax: (510) 549-0334
Map & Directions
Use our patient portal to request appointments, lab/test results, prescription refills, or to send a note to our office.