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New Patient Form

Welcome to our practice

Save time and start your journey to optimized living by filling out this new patient form in advance of your visit.

First Name

Email Address

Last Name

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Reason for Visit

Emergency Contact Name & Phone

Emergency Contact Relationship

Thanks for submitting!

Call us at 949.706.1212

Bar-X-Medspa 9.56.40 PM

2111 San Joaquin Road

Newport Beach, CA

9 am – 5 pm Mon-Fri
Weekends by appointment only

Tel: 949.706.1212

© 2025 Dr. Iman Bar

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