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Your Name

First

Last

Date of Birth

mm/dd/yyyy

Your Address

Address 1

Address 2

City

State

Postal Code

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Your Phone###-###-####

Cell Phone

Your Email

Preferred Contact Method

Snail Mail

Electronic Email

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Primary Reason for Visit If your concern is not listed, write it in the comment section

Back pain

Leg pain

Buttock pain

Neck pain

Arm pain

Other - explain in the Comment section below

CommentsPlease enter anything else you would like to say...

New Patient Registration


Main Menu Home Our Staff Contact Us Map Doctor J View Photo Album Patient Information New Patient Registration What to Expect Education Neck Pain Audio Static Content Click here to read Dr. Johnson's bio. Click here to read Healthy Inland Empire Magazine articles by our columnist, Dr. Johnson. Login Email Password Forgot password? \| Register	New Patient Registration Leave this field blank Leave this field blank Leave this field blank Please fill out the following form completely. When you are finished, click "Submit" Your Name First Last   Date of Birth mm/dd/yyyy Your Address Address 1 Address 2 City State Postal Code Country   Your Phone###-###-#### Cell Phone Your Email Preferred Contact Method Snail Mail Electronic Email Telephone Primary Payment Method Medicare PPO - Private Insurance Regal HMO Primecare HMO Workers Compensation Cash / Credit Card Other {explain in comment section below} Secondary Payment Method Medicare PPO - Private Insurance Regal HMO Primecare HMO Workers Compensation Cash / Credit Card Primary Reason for Visit If your concern is not listed, write it in the comment section Back pain Leg pain Buttock pain Neck pain Arm pain Other - explain in the Comment section below Secondary Reason for Visit Neck pain Arm pain Back pain Leg pain Buttock pain CommentsPlease enter anything else you would like to say...