4955 West Lane
Stockton, CA 95210

Tel:  (209) 956-1480
Fax: (209) 956-1484


If you are a new client or an existing client that has not came in within the past 3 years, please print and fill out the following form. Bring it with you at your visit.


Social security and drivers license numbers are only required if paying via CareCredit. The form must be signed by someone 18 years of age or older or an emancipated minor.

We can always provide the forms for you to fill out when you arrive; this just saves you time! :]