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.
- Fillable PDF New Patient Information
- Fillable PDF Health History Intake Form
- Fillable PDF HIPAA Release
All patients please review Office Payment and Cancellation Policy below. Thank you.
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