Forms


3860 BLACKHAWK ROAD, SUITE 120, DANVILLE, CA

 July Update: 

Due to the recent increase in COVID-19 cases, we will continue to treat patients via TELEHEALTH ONLY. We feel this is the best way to keep our patients and staff safe during this time. We use a HIPAA compliant video chat program called Doxy.me for our visits. Doxy.me does not require any downloads and can be accessed through google chrome on a computer, tablet, or phone that has a camera and microphone.

 If you are already scheduled for an appointment, our office staff will email instructions for your telehealth appointment.

Should you have any questions, please email us at ebpgoffice@comcast.net

If you would like to read more about COVID-19 please see the Centers for Disease Control and Prevention (CDC) website: https://www.cdc.gov/coronavirus/2019-ncov/about/index.html

Privacy Policy

Evaluation forms

Adult New Patient Form (18 years or older)

Minor New Patient Form (under 18 years old OR has a conservator)

Records Request Forms

Fill out this form if you’d like EBPG to send your records to another physician or medical organization:

Record Request for Adult

Record Request for Minor

Fill out this form if you’d like EBPG to request your medical records from another physician or medical organization:

Consent Form for Adult Patients

Consent Form for Minor Patients