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New Patients

To expedite your first visit, please print out and complete the New Patient forms, and bring them with you to your appointment. Thank you!

Michael Heffernan, M.D., Joseph W. Diehl, M.D., and Cheryl Ketelsen, PA-C are all currently accepting New Patients. Please call the office directly to schedule your New Patient appointment at (805) 541-2650 or (805) 541-4180.

You can download and print our New Patient Forms by clicking on the blue links below. Please make sure to bring your Insurance cards, Photo ID, and legible list of Medications including dosage to all appointments. Thank you. New Patient Forms: Please print and fill out the three forms below and bring them to your New Patient appointment.

  1. Fillable PDF New Patient Information
  2. Fillable PDF Health History Intake Form
  3. Fillable PDF HIPAA Release
  4. Patient Assembly Bill Notice

All patients please review Office Payment and Cancellation Policy below. Thank you.

  1. Authorization of Pymt Policy 9-1-17.pdf
  2. Cancellation No Show Policy 9-1-17.pdf

Miscellaneous Forms:

Authorization to treat a Minor 10-2-18.pdf

Credit Card Authorization 9-1-17.pdf

Authorization to Release Records to Outside Physician – Santa Rosa Office.pdf

Auth to Release Medical Records to Patient – Santa Rosa Office.pdf

Authorization to Release Records to Outside Physician – Bishop Office.pdf

Auth to Release Records to Patient – Bishop Office.pdf