Your Contact Information

*First Name:
*Last Name:
*Date of Birth:
*Phone:
*Email Address:

*Medical History

Which of the following conditions do you have? (please check all that apply)

Rheumatoid Arthritis
Psoriatic Arthritis
Lupus
Osteoarthritis
Osteoporosis
Fibromyalgia
Gout
Other

Have you ever taken any of the following medications?
(please check all that apply)

Methotrexate
Adalimumab (humira)
Etanercept (enbrel)
Certolizumab (cimzia)
Golimumab (simponi)
Infliximab (remicade)
Abatacept (orencia)
Tocilizumab (actemra)
Rituximab (rituxan)
Tofacitinib citrate (Xeljanz)

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Contact

Phone

Hemet Office: (951)652-5000
Menifee Office:(951)672-1866
Corona Office: (951) 256-1779
Temecula Office: (951)303-1500
Riverside Office: (951)924-6500
San Bernardino Office: (909)567-2917

Fax Numbers:

(855)306-0133 - Pharmacy
(855)306-0134 - Labs, Radiology
(855)306-0135 - Authorizations