and Consent forms.
arrange a Health Mobile visit;
Please follow the instructions below.
process is simple and efficient, as we are anxious to bring our program to
Contact Director of Patient Relations at Health Mobile, at (408) 879-0110 to
schedule a visit.
Download the Application Form and the Patient Medical History Form.
distribute both forms to all interested
Application and Consent Form ( English) (Spanish) (Korean)
Patient Medical History (
English) (Spanish) (Korean)
Fax the completed Application forms to:
Director of Patient
Relations Health Mobile at (408) 244-9553 or,
you can mail them to:
1659 Scott Blvd. Suite 4,
Santa Clara, CA 95050.
Note: The Patient Medical History forms will be available at the Mobile and
can be completed by the patient before his or her appointment.