Patient Registration Forms

For your convenience, please download and complete the following forms prior to your appointment. After you download the form to your computer you will need to print the forms on your printer. Please complete the forms and bring them with you to your appointment. Alternatively, you can fax or mail the forms to our office

Patient Registration Form
Health History Form
Payment Policy Practice
Notice of Privacy
Consent to Obtain Prescription history

Fax: (530) 222-1219

Mail: Andre Van Mol, MD, 3580 Santa Rosa Way, Redding, CA 96003

Please call (530) 222-3225 if you have any questions.

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