Patient Forms

New Patient Forms

You can download the following forms or pre-register on our secure Patient Portal.

Child Health Form
Initial History Form.pdf
Adobe Acrobat document [127.3 KB]
Face Sheet
Face sheet.pdf
Adobe Acrobat document [143.7 KB]
Financial Agreement
Financial Agreement.pdf
Adobe Acrobat document [46.1 KB]
Cancellation Form
Cancellation From.pdf
Adobe Acrobat document [84.4 KB]
Medical Records Release
Records Release to Our Office.pdf
Adobe Acrobat document [223.2 KB]
Medical Records Release from Our Office
Records from Our Office.pdf
Adobe Acrobat document [186.0 KB]
HIPPA form
HIPPA form.pdf
Adobe Acrobat document [949.2 KB]
Credit Card Policy
Credit Card Policy.pdf
Adobe Acrobat document [278.4 KB]

Commonly Used Forms

Physician's Report- Child Care Centers
Physician's Report- Child Care Centers.p[...]
Adobe Acrobat document [463.3 KB]
Health Exam for School Entry
Health Exam. for School Entry.pdf
Adobe Acrobat document [460.8 KB]
Authorization for Medications at School
Authorization for Meds. at School.pdf
Adobe Acrobat document [476.8 KB]
Youth Football Form
Pacific Youth Football League.pdf
Adobe Acrobat document [288.3 KB]

Voted "Winner"

Pediatrician

East County 

2017

 

Voted "Favorite" Pediatrician

East County

2015

2016

Dr. Dog says "Stay water safe this summer!"

Office Hours

By Appointment Only

 

Monday - Friday

9:00 am - 5:00 pm

 

Saturday

9:00 am - 12:00 pm

Conejo Children's Medical Group

558 N. Ventu Park Rd.

Suite D

Thousand Oaks, CA 91320

 

Phone  (805) 499-5525

Fax       (805) 499-5554

email: frontoffice@conejochildrens.com

 

Patient Portal:

https://health.eclinicalworks.com/conejochildrens

 

 

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