New Patient Packet

The New Patient Packet contains forms which are to be completed prior to seeing the clinician. The forms must be returned to MCLA 5 business days after you have secured your appointment. If you are unable to return the forms within 5 business days, call the office to make other arrangements. Please follow the instructions carefully and remember to bring the requested items.



Click here for New Patient Packet

Instructions

Download Instructions:

  • Open the document
  • After the form is open, right click your mouse and click "Save As" - save the form to your Desktop. Choose a file name you will remember e.g. MyInformation.pdf.
  • Once you have saved to your desktop, exit this website and click the MyInformation.pdf on your desktop.
  • You can now begin filling in the document.
  • Once completed, go to the menu at the top of Acrobat Reader and click "File" At the dropdown menu click "Save As."
  • Save the form to a folder or directory of your choice. We suggest adding the current date eg. MyInformation-4-10-17.pdf. Adding the date lets you know which information is most current.
  • Print your completed form

 

For your security please bring your completed Form to the office or print the pages and fax to:

(818) 545-7672.

     

    Please Note:  Typing your name to the pages in this document makes this document legal and binding.

Medical Records Release

To request release of your medical records from MCLA to a third party, download this form and bring it with you to the office.



Click here for Release of Information

Instructions

Download Instructions:

  • Download and print document.
  • Manually fill in all fields
  • When finished print out document

 

For your security please bring your completed Form to the office or print the pages and fax to:

(818) 545-7672.

Authorization Form

You may use this form to authorize having your records sent to MCLA.



Click here for Authorization Form

Instructions

Download Instructions:

  • Download and print document.
  • Manually fill in all fields
  • When finished print out document

 

For your security please bring your completed Form to the office or print the pages and fax to:

(818) 545-7672.