Four Seasons Surgery Center has three Californian locations.
Anaheim, CA
1324 S. Euclid St.
Anaheim, CA 92802
Phone: 714.262.0047
Fax: 714.262.0060
Huntington Beach, CA
17762 Beach Boulevard
Huntington Beach, Ca 92647
Phone: (714)842-1426
Fax: (714)849-3737
Ontario, CA
1211 W. Sixth Street
Ontario, CA
91762
Phone: 909.933.6580
Fax: 909.933.6590
Patient Registration
Welcome New Patients!
Thank you for choosing Four Seasons Surgery Center. We are confident that you will experience quality care and service when visiting our facilities. In order to reduce patient wait times we are providing you with the necessary registration forms that should be printed and completed prior to your arrival for your scheduled appointment. The forms included in this registration packet help us to prepare an accurate medical record and gather important information regarding your current health status, allergies, emergency contact and insurance information. You will need adobe acrobat in order to open and print these files.
Registration Packet
1) Patient Registration Form (two pages in length) |
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Please make sure to complete all sections, answer all questions and sign where indicated. |
| Patient Registration Form |
2) Advance Health Care Directive Acknowledgement |
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Do not forget to bring a copy of your current Advance Health Care Directive if you answer Yes to having one. |
| Advanced Health Care Acknowledgement Form |
3) Standard Authorization of Use and Disclosure of Protected Health Information (PHI) |
| Authorization of Use and Disclosure of Protected Health Information Form |
4) Notice of HIPAA Privacy Practices (two pages in length) |
| HIPAA Notice Form |
5) Physician/Patient Arbitration Agreement |
| Physician/Patient Arbitration Agreement Form |
6) Data Collection for OSHPD |
| Data Collection for OSHPD Form |
7) Patient Acceptance of Financial Responsibility (two pages in length) |
| Patient Acceptance of Financial Responsibility Form |
Thank you in advance for your cooperation. If you have any questions regarding the forms, please contact the facility where you intend to have your procedure at the number shown above.