Clinic New Patient Forms & Rates

Planning for Your First Appointment

If you are a new patient to the Yo San University Community Clinic, please arrive 15 minutes prior to your appointment time to fill out the New Patient Forms.

• New patients with appointments with a Master’s Intern, Specialty Clinic (Healthy Aging & Internal Medicine and Orthopedics & Pain) or a Private Practitioner, please fill out and bring the following forms to your appointment:
  • Patient Personal Data Form
  • Patient Medical History
  • YSU Teaching Clinic Office Policy
  • Notice of Privacy Practice Patient Acknowledgement
  • YSU Clinic Payment Policy
  • New Clinic Client Survey
  • Authorization to Treat A Minor (if applicable)*

*For the treatment of minors, the parent or guardian must be present in the treatment room with the minor and practitioner at all times during the appointment.

• New patients to the Women’s Health and Reproductive Medicine Specialty Clinic, please fill out and bring the following forms to your appointment:

Female Fertility Forms
Male Fertility Forms

For all patients, please read YSU’s Notice of Privacy Practices which describes your rights, choices and uses/disclosures of your health information.

Rates

Please view our current Clinic Fee Schedule for community patients, YSU students, YSU faculty, YSU alumni and YSU family members. Yo San University Community Clinic rates are subject to change.

If you have any questions about the new patient forms or rates, please contact a clinic receptionist at (310) 577-3006, M-F 8:00 am – 9:00 pm, Sa-Su 8:30 am – 5:30 pm.