New Patient Forms

You can accelerate your check in process by completing the forms below before you have your first visit to our office. You may fill them out online or download, print and mail them to us. You may also click here to upload "before" photos to be evaluated by the doctor.

Forms

Patient Consent Form

Use and Disclosure of Health Information Protected under HIPAA

Download PDF

Confidential Medical History

Download PDF

How to Send Us Your Forms

Mail

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 address:

Steven Teitelbaum MD FACS
Attn: Vicki Koplow

1301 Twentieth Street, Suite 350
Santa Monica, CA 90404

Fax

You may fax these forms to:

310.315.9921
Attn: Vicki Koplow

Email

You may also email these forms:

E-mail Us