Contact us to schedule your appointment today.

Call us at 1-310-447-6141

Or fill out the following form and one of our staff will get back to you to confirm your appointment during our working hours.

( Providing us with this information now will help speed up your check-in process )

For patients under the age of 18

A signature from the parent is required for all patients younger than 18 at the time of the appointment. The Prescription Form provided to you by the referring doctor has additional information on the back including a place for the parent’s signature. Please sign and date that form now and make sure you bring it with you to the appointment. No X-rays will be taking without it!

Patient's Name
Patient's Name
Legal Guardian's Name (If the patient is under the age of 18)
Legal Guardian's Name (If the patient is under the age of 18)
Patient's Sex
Patient's Birthdate
Patient's Birthdate
Home Phone Number
Home Phone Number
Work Phone Number
Work Phone Number