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New Patient Registration Forms

Preparing for your first appointment at Buellton Medical Center has just gotten easier! Print out the following forms (either in English or Spanish), complete them, and bring them to your appointment to speed up the registration process.  You may also do the registration process electronically!  When making the appointment with our receptionist, please ask for patient portal access.  We also provide a iPad at the office if you prefer to register here.

We look forward to caring for all of your healthcare needs!


For Adult Patients (age 21 and older)


New Patient Registration - English

New Patient Registration- Spanish

Medical History Intake Form - English


Medical History Intake Form - Spanish


For Pediatric Patients (age 21 and younger)


New Patient Registration Form - English

New Patient Registration- Spanish


Pediatric Health History Form - English


Pediatric Health History Form - Spanish


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