top of page

Patient Enrollment Forms:

Please print out and complete at your convenience. You can mail the completed packet to the office (2150 Main St, Ste. 3, Cambria, CA, 93428), email (info@coastalpinesmedical.com), or call the office to schedule a time to drop off (805-927-1673). Thank you. We look forward to connecting with you soon!

CPMG Patient Enrollment Process - Google Docs (1).jpg

Patient Enrollment

1 CPMG PT PKT cover sheet 1 copy.png

PT PKT

2 CPMG Communications Form 21 copy.png

Communications Form

3 CPMG Patient Intake Form Final1 copy.jpg

Patient Intake

4 CPMG Medical Release Form 4 copy.png

Medical Release Form

5 CPMG Pt R&& Attestation 5 copy.png

Pt R&& Attestation

6 CPMG Privacy Practices Attestation 6 copy.png

Privacy Practices Attestation

7 COASTAL PINES MEMBERSHIP AGREEMENT rev Feb 11 20221 copy.png

Membership Agreement

8 CPMG Financial Agreement 81 copy.png

Financial Agreement

9 CPMG Notice of Privacy Practices 91 copy.png

Notice of Privacy Practices

10 CPMG PT Rights _ Responsibilities 101 copy.png

PT Rights  Responsibilities

2023 CPMG Fee Structure.jpg

Fee Structure

2023 CPMG Amenities list and fees.jpg

Amenities

CPMG Membership Application 2023 Pricing

Membership Application

bottom of page