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Ampla Health- Medical and Dental Services for Northern California
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Registration Forms

Home Registration Forms

We want to answer as many of your questions at your visit.

Please arrive 20 minutes before your appointment.

These are the items you should bring to your appointment with Ampla Health.

Please prepare for this by bringing:

  • Patient Registration Form
  • Confidential Medical History:
  • Adult (Ages: 11 years to Adult)
  • Children (Ages: Birth to 10 years)
  • Medication/Prescription List
  • Female Confidential History Form
  • Drivers License or State Issued Identification Card
  • Primary and Secondary Insurance Cards
  • A list of your questions and concerns
  • A list of your past medical history and surgeries
  • A copy of your XRAYS / CT scans (not just the reports – please bring the actual films)
  • Copies of Records from doctors related to your medical history

Patient Forms

Please be advised patient forms will be accessible in Ampla Health’s Patient Portal.

Patient Portal
** Ampla Health accepts most insurance plans including Medi-Cal Managed Care options, California Health and Wellness and Anthem Blue Cross Partnership Plans, Medicare, and private pay. **
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Corporate Office

935 Market Street, Yuba City, CA 95991 (530) 674-4261
Toll Free # 1-866-358-9791
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