icon-close.svg

Forms

Confidential Medical History

Download PDF

Patient Consent Form: Use and Disclosure of Health Information Protected under HIPAA

Download PDF

You may fax these forms to:

310.315.9921

Attn: 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:

E-mail Us

© Steven Teitelbaum MD, A Medical Corporation. All Rights Reserved. Designed & Developed by Studio III in collaboration with air conditioned la

A Message from Dr. Teitelbaum concerning COVID-19 View Update Online Consultation

Practice Policy Update Regarding COVID-19

We’re Still Open… well, sort of.

While we have not resumed regularly scheduled office hours, Vicki and Dr. Teitelbaum are nearby and available for past and current patients at 310.315.1121.

While we are all sheltering at home, Dr. Teitelbaum is offering everyone the same phone and video consultations he has always done for out-of-town patients. He expects to be operating again soon.

You may also reach Vicki at [email protected] . Stay safe.

Online Consultation