New Patient Forms

Welcome to our Practice! (the name is pronounced  ” Duke  Doe” ).  

Please download the following forms to fill out:

New Patient Forms

The forms along with a copy of the front and back of your insurance are due 4 weeks prior to your first appointment. Forms can be turned in via email, fax, or mailed to us. Note: If emailed, the forms are needed to be in PDF format.

* Due dates may change based on holiday season.

Please note:  Insurances we accept are:

  • All PPO, except Blue Shield Exclusive Individual plans or Covered California Insurance Plans
  • HMO plans with Greater Newport Physicians-Hoag or Edinger Medical Group
  • Medicare

 Email:  DucDoEndo1@gmail.com    

355 Placentia Ave.; Ste. 207A   NB, CA 92663 

Phone: (949) 574-4114      Fax:  949-574-4144

We will try our best  to  obtain your medical information from the referring physicians.  Remember that it may take days to weeks for record to be sent to us. If necessary, you can download the Release-of-Record form if required by the referring office.

Release-of-Record

Sometimes the best way is to pick up the record yourself and email or send to us prior to your appointment. 

Please  email/fax/mail to to us  prior to  your appointment:  

  • The new patient forms (completely filled out)

  • Insurance card

  • An updated list of all your medications or the original labels (including all prescription drugs, vitamins, supplements, herbs, etc.) (if applicable)
  • Any pertinent medical record that you may have
  • An organized log of your glucose testing if you have diabetes

Please note:  Copays are due at the time of service (cash, card payments, or check) *NOTE: ALL card payments are subject to a 3% transaction fee.

We do require that rescheduling and cancellation be done 24 hours prior to your appointment, not including holidays and weekends. Rescheduling or cancellations must be done with a live agent. Phone messages will not be accepted. Any less than 24hr cancellations and no-show appointments may be subject to a fee of $30. 

1