office (626) 200-4500
Jacklin Poladian, M.D. Inc.                        fax (626) 795-0704

Internal Medicine                       800 S. Fairmount Ave, Suite 420

Pasadena, CA 91105


New Patient Forms

Please read the Physician-Patient Arbitration Agreement prior to your  appointment.

Physician-Patient Arbitration Agreement


Please complete, print and bring the following forms with you to your appointment. For the purposes of HIPAA-compliance, please do not email completed forms to our office.

Records Transfer Request Form
To request your health records from other physicians please use the form above.

Patient Registration Form

Patient History Form

Patient's Rights & Responsibilities

HIPAA Notice of Privacy Practices

Authorization to Release Medical Records From Dr J. Poladian to Patients and Other Institutions

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