Make an Appointment: info@debramyersmd.com | 310-995-7682

info@debramyersmd.com | 310-995-7682
Contact

Client Forms

Client Forms

If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.

Patient Intake Form

HIPAA Informed Consent

Telehealth Agreement

Release of Information

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Authorization for Release of Information

2052 Bundy Drive #1021 West
Los Angeles, CA 90025

310-995-7682
info@debramyersmd.com

By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.