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
    Encinitas Office: (951) 303-1500
    La Jolla Office: (951) 303-1500

    Fax Numbers:

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