Welcome to the only wellness center to thoroughly approach all of your aesthetic and health care needs in one practice. To begin, please complete our PlatinumCare LA New Patient Form below so we can have you on file.¬†Whether you’re here for our Primary Care or our MedSpa, we look forward to working with you to help you become the healthiest and best version of yourself. We will be in touch soon. If you have any questions, please contact us.

Full Name:

Date of Birth:

Gender:

Address:

City:

State:

Zip:

Home Tel:

Mobile:

Email:

Ethnicity:

Martial Status:

SSN:

Pharmacy:

Employer:

Click here for our other PlatinumCare LA Forms.