Patient Forms – Request to Schedule – Genetics Center

Toggle menu

Search Our Website:

Skip to Main Content

Home
Test Menu
Services
Forms
Training Programs
Careers
Notices
Contact Us
About Us
F.A.Q.

Search Our Website:

Request To Schedule A Pediatric Appointment

Demographics Last Name * First Name * Middle Name Date of Birth (MM/DD/YYYY) *
Parent 1 Last Name Parent 1 First Name Parent 2 Last Name Parent 2 First Name
Home Address * City * State * Zip *
Phone Number (best contact number) * Phone Type:*    Cell     Home     Business Contact Person:*    Parent 1     Parent 2     Other
Phone Number (other) Phone Type:    Cell     Home     Business
Primary Language:    English        Spanish     Other:

Referral Source Information Referring provider * Referring provider office location * Referring provider phone Primary Care Doctor

Medical Information Reason for being referred?
Do you have any family history of autism, down syndrome, or any other condition?:    Yes     No If yes, list condition(s)
Is the patient taking any medications?    Yes     No
List medications
Have you had any genetic testing?:    Yes     No
If yes, which tests?

Insurance Information Primary Insurance HMO or PPO?: HMO PPO Member ID #
If an HMO, medical group assigned to? Authorization Number
Secondary Insurance HMO or PPO?: HMO PPO Member ID #
If an HMO, medical group assigned to? Authorization Number

We will contact you at the best phone number listed above to assist you further.

* If you are experiencing difficulties with this form, please contact (714) 288-3500 for assistance. Thank you.

Copyright 2023. Genetics Center, All Rights Reserved

Contact Us

211 South Main Street, Orange, California 92868

1-888-4-GENETIC

Monday-Friday 8am-5pm

Request to Schedule Telecounseling Make a Payment