714-901-7777
New Patient Form

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Medical History

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Communication Authorization Form

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Financial Policy

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Notice Of Privacy Practices

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Notice Of Privacy Practices Acknowledgement Form

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There are 5 forms that you will need to complete for your scheduled appointment:

    • VMRI New Patient Information Form

    • VMRI Patient Medical History Form

    • VMRI Financial Policy Form

    • VMRI Notice of Privacy Practices Acknowledgement Form.

      • Please read the corresponding Notice of Privacy Practices before signing. You may print the Notice for your records.
    • VMRI Communication Authorization Form

You have 5 options for handling the forms on the website:

  • You can complete the form on-line, print and bring forms to your appointment.

  • You can complete the form on-line, print and fax to (714) 901-7770.

  • You can complete the form on-line; click “submit form” and the form will prompt you to submit using your preferred e-mail system to reply@vmrinstitute.com

  • You can complete the form on-line, apply a digital signature (see directions below) and send form as an e-mail attachment to: reply@vmrinstitute.com

  • If you have any trouble with the on-line forms, we will provide you the forms at the time of your appointment.

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Instructions for using a digital signature (optional):

  • Make sure you have completed the form before applying a digital signature, as changes will not be allowed after signing.

  • Click on the “Signature Box.”  This will prompt you to create a Digital ID or you can use one you already have.  Your Digital ID can be used for signing all forms.

  • If you do not already have a digital signature, click on “A New Digital ID I want To Create Now.” Click Next.

  • Select the default option “New PKCS#12 digital ID file.” Click Next.

  • Enter your Name and e-mail address.  You do not need to enter any other fields; leave the other default options. Click Next.

  • Save the digital ID in your computer, set a Password and Confirm Password. Click Finish.

  • You will get a box with your Digital Signature.  You may change the appearance or leave as is.  Enter your password and Click Sign.

  • Save your document to your computer.  You should now see that the document is signed and valid.

  • Submit completed, signed document as an attachment using your preferred e-mail system.  E-mail to:  reply@vmrinstitute.com

  • You can use this digital signature on subsequent forms by Clicking on the “Signature Box” and entering your password to apply the digital signature you already created. Click Sign.  Submit completed, signed document as an attachment using your e-mail system.  E-mail to:  reply@vmrinstitute.com

 

 
VMR Institute7677 Center Ave. #400
Huntington Beach, CA 92647
714.901.7777