Patient Registration Form

"*" indicates required fields

1Patient Information
2Additional Information
3Insurance Information
MM slash DD slash YYYY
Registration Type
Select Your Doctor

Personal Information

Patient's Name
MM slash DD slash YYYY
Sex Assigned at Birth
Patient's Address
Marital Status
Primary Care Physician
Referred By

Employment Information

Employment Status
Employer Address
Wallace & Lee Center

8750 Wilshire Blvd Suite 210,

Beverly Hills, CA 90211

Main Office Phone: (310) 652-0920
Main Office Fax: (310) 360-4812
Research Phone: (310) 360-9197
Research Fax: (310) 360-6219

Infusion Phone: (310) 360-4806

Billing Phone: (310) 652-2284

Billing Fax: (310) 855-9309

Email Address:

office@walleemed.com

Mailing Address

PO Box 18736,

Beverly Hills, CA 90209

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