1134 S. Robertson Blvd
Los Angeles, CA 90035
T (310) 274-6089
F (310) 274-6012

Patient Registration

Patient Name

Home Address

Contact

Employment

If Patient is Married

RESPONSIBLE PARTY (If Patient is under 18 years of age, please provide parent/guardian's information)

All Patients

Insurance

Secondary Insurance

We are not providers for any dental, medical or medicare insurance carriers. As a courtesy we will submit a claim to your insurance company (except medicare) and reimbursement will be directed to the insured.


Who can we thank for referring you?


Medical History


Have you ever had any of the following?



















Please indicate if you have ever experienced an unusual or allergic reaction to any of these medications:

I hereby certify that the above information is true and accurate and there have not been any omissions from my medical history. I consent to the taking of clinical photographs for the purpose of treatment and/or educational use. I authorize the release of any information to my insurance companies. I understand that Dr. Sheerin and or Dr. Wang is not a provider for any medical or dental insurance plans and is not a Medicare provider. I understand that I will be financially responsible for all charges incurred and payment is due at the time that services are rendered. Should it be necessary to take any action against any of the parties to this agreement to enforce the provisions thereof or to take any action which is related to or arises out of this agreement, Dr. Sheerin and or Dr. Wang shall be entitled to all cost and expenses including but not limited to attorneys fees, service charges and collection agencies fees incurred therein but not to exceed $5,000. Accounts extending over thirty days will be charged 0.833% interest per month.