To obtain a free version of Adobe acrobat (program to read the .pdf file if your computer doesn't already have it installed), click here To obtain a free version of a document reader (program to read the .doc file above if your computer doesn't already have it installed), click here
Please submit forms and a copy of your insurance card at least 2 days before your visit, your wait time will be less.
1) Registration form: click here for the .pdf file.
2) Patient Satisfaction Survey Form: click here for the pdf; click here for the .doc file
You may fax 925-962-9122
or you may mail (Attn: Suzanne Sommer, 911 Moraga Road #101, Lafayette, CA 94549),
3) Health History Form for New Patients: click here for the .pdf file; click here for the .doc file
4) Yearly Physical Exam form click here for the .pdf file; click here for the .doc file
Department of transportation commercial driver physical form click here to go to the website.
5) Worker's Compensation
Physician Designation Form: click here for the .pdf file; click here for the .doc file
Dr. Sommer MUST sign this form before you can submit it to your employer
6) Forms for Travel Appointments Immunization record: Click here for the .pdf file; click here for the .doc file
Itinerary and medical history: click here for the pdf or here for the .doc file
7) Record Release form so you former provider can mail/fax your medical records:
click here for the pdf file; click here for the .doc file