New Urology Patient Registration Form

Welcome to Pacific Urology! Please use our convenient online form to complete your new patient paperwork prior to your appointment.

Our commitment to your privacy and security

Health forms often ask for a large amounts of highly personal information. At Pacific Urology we are dedicated to ensuring your privacy and use an online form that is fully encrypted, extra security to prevent unauthorized access to your information. Information from this form is also stored in an encrypted database.

Items you will need to complete this form

  • A list of your current medications.
    A list of your physicians, including their phone number, practice location and their speciality.
  • A list of your medical, social and family history, such as past surgeries, diseases and other conditions.
  • Optional: Photos or scanned copies of the front and back of your health insurance ID card(s).

Tips for using this form

  • Depending on your appointment type, this form takes approximately 30 minutes to 1 hour to complete.
  • To complete the form you will need a stable internet connection.
  • Use the most up-to-date version of your web browser; we recommend using either Chrome or Firefox. Enable Javascript and cookies in your browser (these are typically on by default).
  • If you plan on uploading images of your insurance ID card, save images of the front and back of your insurance card on your computer or phone before starting this form. Upload images that are 5 MB or smaller in size. Large images may prevent you from being able to complete the form.
  • Don’t click on your browser’s back button, you may lose data you’ve previously entered.

If you have to stop filling out your form before it was fully completed: You can use the “Save and Resume Later” button at the bottom of each form page to come back later; just enter a password you’ll remember and Formstack will email you a link to your form.

Please complete the New Patient Registration online form below

* Indicates required field