Forms

Please click on the links below to download each form. For new patients, you will need to fill out the following:

Patient Registration Form
Patient Medical History Form
Assignment of Benefits Acknowledgement
Financial Responsibility Acknowledgement
HIPAA Consent
Office Policies Acknowledgement

If you are transferring from another facility or physician, or have records that need to be reviewed by Dr. Hage, please complete the Records Release Form below. You may complete these forms online and print them or you may print them and complete them manually; please do so prior to your visit and be sure to bring them with you to your appointment.

To register at Redlands Community Hospital for maternity, please use the Hospital Registration Form below.

If you need disability forms for surgery or maternity leave, use the Maternity/Disability Form below. For more information on Family Medical Leave and for other related forms, please go to the Employment Development Department website at www.edd.ca.gov.

New Patient Forms

Patient Registration Form
Patient Medical History Form
Assignment of Benefits Acknowledgement
Financial Responsibility Acknowledgement
HIPAA Consent
Office Policies Acknowledgement

Pregnancy Related Forms

Birthing Plan
Fetal Movement Chart
EDD Maternity/Disability Form
Redlands Community Hospital Pre-Registration Form

Records Release Forms

Records Release Form (FROM Redlands OB/GYN)
Records Release Form (TO Redlands OB/GYN)