Please download, print, and complete ALL forms provided in the link.

If you have any questions on the Patient Intake Form, please call the office at 805-612-5293. 

For billing and insurance questions, email Victoria House at    

Please remember to bring your completed forms, along with the following pieces of information, to your scheduled appointment:

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• Insurance card

• Photo ID

• Referrals (If required by your insurance)

• Co-payments (If required by your insurance)

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Please use the link provided to download and print the patient forms. 

 

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• If you are using insurance, please click on the button below and complete the Insurance Form:

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• If you are paying privately, please click on the button below and complete the Private Pay Form:

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Send the Patient Information & Financial Agreement Form

to the billing office at: VHOUSE@HOUSEBILLING.COM 

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Fax to (866) 849-0672.

*YOUR INFORMATION WILL BE VERIFIED AND CONFIRMED VIA EMAIL*

 

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Financial Policy ​

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We require prior verification of eligibility in order to use insurance as the method of payment. If insurance has not been verified, the appointment will be charged out-of-pocket and the fee will be collected at check-in. 

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To download Adobe Acrobat Reader for free, click here.

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