Online Forms

Life & Health Wellness Center offers our patient form(s) online so they can be completed in the convenience of your own home or office.

  • If you do not already have AdobeReaderĀ® installed on your computer, click here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Or Fill-out our Online Intake Form below.

By providing your phone number to this agency, you agree that we may send you text messages. Message and data rates may apply. Message frequency will vary. Reply STOP to opt - out of future messaging or HELP for more information. Please refer to our Privacy Policies for more information about how we manage your data.  

No mobile information will be shared with third parties for marketing or promotional purposes. All the above categories exclude text messaging originator opt-in data consent; this information will not be shared with any third parties

Online Patient Intake Form

Locations

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Riverside Hours

Monday:

Closed

Tuesday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Wednesday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Thursday:

Closed

Friday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Saturday:

Closed

Sunday:

Closed

Santa Ana Hours

Mon:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Tue:

2:00 pm-7:00 pm

Wed:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Thu:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Fri:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Sat:

appointment only

Sunday:

Closed

Rancho Cucamonga Hours

Mon:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Tue:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Wed:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Thursday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed