Patient Forms

Patient Forms

NEW PATIENT REGISTRATION AND IMPORTANT FORMS

Download the New Patient Registration and Information package (PDF). Complete and bring with you for your first visit.

HMO PATIENTS FORMS – If you are an HMO patient and are associated with one of our participating medical groups*. DOWNLOAD THIS FORM.

*Pacific Coast Urology Medical Center is contracted with Arta Medical Group, Prime Health Care and Regal Medical Group.

PPO & CASH PATIENTS FORMS – If you are a PPO patient or paying cash. DOWNLOAD THIS FORM

Your Financial Responsibility

Please read our payment policies for your financial responsibility. If you require assistance with verifying or understanding your health plan benefits and any associated co-pays or deductibles, we are happy to help. Please call our office at 888.735.4336 and we will connect you to our Financial/Insurance Department.

NO NEEDLE NO SCALPEL VASECTOMY PATIENTS FORM

If you are a vasectomy patient, please read the State mandated vasectomy consent form. This consent form is required along with your new patient registration forms. During your initial visit with Dr. Pugach will review the form with and obtain your signature. You are required to wait a minimum of 72 hours prior to receiving your vasectomy.

State of California Vasectomy Consent Form (ENGLISH- DOWNLOAD THIS FORM)

State of California Vasectomy Consent Form (SPANISH – DOWNLOAD THIS FORM)

IF YOU HAVE ANY QUESTIONS ON OUR FORMS OR HAVE ANY DIFFICULTY DOWNLOADING THE FORMS, PLEASE CALL: 888-735-4336