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

 

© 2013 Buellton Medical Center. All rights reserved.

Buellton Medical Center

195 W. Hwy 246

Buellton, CA 93427

Main: (805) 686-8555

Fax: (805) 686-8556

Email: info@buelltonmedicalcenter.com

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Mon - Thurs             8:30 am - 6:00 pm
Friday                        8:30 am - 4:30 pm

Saturday                   9:00 am - 2:00 pm
Sunday                     Closed - Out wine-tasting.