Forms
Confidential Medical History
Download PDFPatient Consent Form: Use and Disclosure of Health Information Protected under HIPAA
Download PDFYou may fax these forms to:
310.315.9921Attn: Vicki Koplow
If you wish to mail these forms to our office in advance of your first visit, we strongly recommend that you use a shipping method with tracking, such as USPS Priority Mail, FedEx or UPS. All forms should be mailed to our office at the following adddress:
Steven Teitelbaum MD FACS Attn: Vicki Koplow 1301 Twentieth Street, Suite 350 Santa Monica, CA 90404
You may also email these forms:
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