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 "Be Thankful for your health and get your flu shot!"

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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