Topanga Medical — Patient Intake

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Patient Information (Part I)

Last Name*

First Name*

MI

Sex

MaleFemale

Address*

City*

State*

Zip*

Date of Birth*

Age

SS#

Marital Status

Home Phone #

Work Phone # or other phone # (Required)*

Employer — Name

Employer — Address

Name of Spouse / Emergency Contact

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Physicians & Pharmacy

Referring Physician — Name

Referring Physician — Address

Referring Physician — Phone #

Primary Care Physician — Name (Required)*

Primary Care Physician — Address (Required)*

Primary Care Physician — Phone # (Required)*

Cardiologist

Pharmacy — Name

Pharmacy — Phone #

Personal Email Address

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Insurance Information

PLEASE GIVE US YOUR CARD TO PHOTOCOPY. CO-PAYMENTS ARE DUE AT THE TIME OF VISIT

Primary Carrier

ID#

Subscriber's Name

Subscriber's Date of Birth

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Authorization & Assignment of Benefits

I HEREBY AUTHORIZE C.J. SPECIALTY SURGICAL ASSOCIATES TO FURNISH INFORMATION CONCERNING MY ILLNESS AND TREATMENT TO THE INSURANCE CARRIERS. I ALSO HEREBY ASSIGN C.J. SPECIALTY SURGICAL ASSOCIATES PAYMENTS FOR MEDICAL SERVICES RENDERED TO MYSELF. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.

Signature of Patient (or Responsible Party, if Minor)*

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By signing above you confirm the information provided is accurate to the best of your knowledge. Signed electronically on September 12, 2026.

Date

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Only If Auto Related

* ONLY IF AUTO RELATED: COMPLETE INFORMATION BELOW

Date of Accident

Auto Related

YesNo

Job Related

YesNo

Claim #

Adjuster

Phone #

Insurance Company — Name

Insurance Company — Address

FOR WORKER'S COMPENSATION AND NO FAULT CASES, IF PAYMENT IS NOT RECEIVED WITHIN SIX MONTHS I AM RESPONSIBLE FOR FULL PAYMENT TO THE PHYSICIAN.

Signature of Patient (Responsible Party, if Minor)*

Sign here

By signing above you confirm the information provided is accurate to the best of your knowledge. Signed electronically on September 12, 2026.

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Reason for Visit (Part II)

Last Name

First Name

Date✓ From EHR

Reason for Visit (Check Below)

Reason

Yes/No

Other (Specify)

Date of First Symptom

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Patient History

Condition

Yes/No

Cancer (specify type)

Other (Specify)

Did you have a colonoscopy?

YesNo

Date of your Last Colonoscopy

Weight

How long have you been at this weight

Height

Do you have an Advanced Directive? (Living Will)

YesNo

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Tobacco & Alcohol Use

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Allergies & Medications

Are you allergic to latex?

YesNo

Are you allergic to penicillin?

YesNo

Allergies to Medications

No entries yet.

List of Current Medications (Dosage and Frequency)

No entries yet.

Previous Surgeries (Dates, Hospitals and name of Surgeon)

No entries yet.

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Family History

Condition

Member & Age

Yes/No

Cancer (Specify type and family member)

Other (Specify)

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Review of Systems (Part III)

Indicate below all that apply to you on a regular basis

Last Name

First Name

Date✓ From EHR

General

Symptom

Yes/No

Eyes

Symptom

Yes/No

ENT

Symptom

Yes/No

Heart

Symptom

Yes/No

Lungs

Symptom

Yes/No

GI

Symptom

Yes/No

GU

Symptom

Yes/No

Ortho

Symptom

Yes/No

Skin

Symptom

Yes/No

Neuro

Symptom

Yes/No

Psych

Symptom

Yes/No

Endo

Symptom

Yes/No

Heme

Symptom

Yes/No

Immune

Symptom

Yes/No

Have you had a pneumonia vaccine in the last 5 years?

Have you had the flu vaccine this season?

I confirm that the information on this form is accurate and authorize Rempli to share it with my healthcare provider. I understand my EHR data was accessed using my patient portal login and may be stored by Rempli to pre-fill future forms.