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Patient Forms

The links below will take you to a Word document created to help track your experience with either Symilin or Byetta.  You can print this document, complete the information and fax it to EMMC at (650) 566-9825.  Or you can save the document to your computer, add in your information, save your changes and email the document back to EMMC as an attached file.  You can email them to: [email protected] .

Symlin Therapy Management Form
Byetta Therapy Management Form
Byetta Program Payment Form
EMMC FAX Cover Sheet

New Patient Forms

Patient Information Form (registration form)
Initial Patient History
New Patient Packet

Privacy Practices
Acknowledgement of Receipt of Privacy Practices

 

 

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Contact EMMC | Endocrine Metabolic Medical Center, Tel.: (650) 566-9810  Fax: (650) 566-9825