REGISTER FOR A HOUSECALL APPOINTMENT HERE
You may start the registration process for yourself or a loved one by contacting us through one of two ways:
Option 1. Call 650.357.8834 (extension 1 for new patients)
Option 2. Fill out our Secure Online New Patient Enrollment Form
YOU MUST CALL THE OFFICE TO COMPLETE THE REGISTRATION PROCESS.
Once the appointment has been set up, there are several forms we need signed before we can begin working with your family. Typically, most people enter their information directly into their medical record, after obtaining a portal password from the office. Several forms need to be printed and signed.
Please fax these documents to: 650.357.8811 (fax); or, if needed, we will make other arrangements with you.
Forms—Download and Fill Out all 7 Forms Below
In addition, new patients also receive a welcome letter, which sets out additional information about our services, coordination of care, and so on.
Initial Contact Information Form
This will provide more information about the concerns that are to be addressed. The examination will be less time-consuming and easier for the patient if the questionnaire is completed prior to the appointment. You may be instructed to input this from the web portal or fax it back.
Patient Demographics Form
This provides basic patient and insurance information about the patient which needs to be completed and returned to us.
- Professional Services Agreement
This form details what services are provided by ElderConsult Geriatric Medicine.
Authorization to Release Medical Information
This form allows us to legally exchange information with other healthcare providers. It needs to be signed and dated.
- Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. It needs to be signed and dated.
- Medicare Opt Out Contract
This form states that the patient/patients representative understands that since Dr Landsverk has opted out of Medicare, Dr Landsverk cannot bill Medicare for her services.