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


For Adult Patients (age 21 and older)


New Patient Registration - English

Medical History Intake Form - English


Medical History Intake Form - Spanish


For Pediatric Patients (age 21 and younger)


New Patient Registration Form


Pediatric Health History Form - English


Pediatric Health History Form - Spanish


For all patients:


Ethnicity/Race Questionnaire


Buellton Medical Center

195 W. Hwy 246

Buellton, CA 93427

Main: (805) 686-8555

Fax: (805) 686-8556



Please call, we are here to serve you

Mon - Thurs             10:00 am - 5:00 pm

Wednesday              10:00 am - 1:00 pm
Friday                        10:00 am - 4:00 pm

Saturday                   9:00 am - 2:00 pm
Sunday                     Closed 

  • Facebook Classic

© 2013 Buellton Medical Center. All rights reserved.