• Membership Information Request Form

    Please tell us how to best contact you with more information about our practice.
  • Gender
  •  -
  • Have you been a patient of Dr. Wallis in the last 5 years?
  • How did you find out about Beach Cities Medicine?

  • Would you like information and enrollment forms for membership with Beach Cities Medicine sent to you?

  • PLEASE NOTE:  Some people are not recieving information when requested due to it landing in their "junk" or "spam" filters;  If you do not hear from us within 24 hours, please check there and if you do not find it, please reach out to us again.

  • Would you like a phone call regarding enrollment in Beach Cities Medicine?
  • Are you, or do you have, a patient representative who is completing this form for another person, for example a dependent parent
  •  -
  • Are you interested in enrolling a second member of the same immediate family?
  • Date of Birth, Additional member (#2)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in enrolling a third member of the same immediate family?
  • Date of Birth, Additional member (#3)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in enrolling a fourth member of the same immediate family?
  • Date of Birth, Additional member (#4)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in enrolling a fifth member of the same immediate family?
  • Date of Birth, Additional member (#5)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in enrolling even more members of the same immediate family?
  • Should be Empty: