SAN DIEGO SURGICAL SPECIALISTS
General, Plastic, and Bariatric Surgery
Main Telephone:    858-565-0104
Dr. Larry Pollack:   858-565-7588

Patient Forms

If you are a new patient, please download, complete, and bring the following forms with you to your appointment:

Patient Demographic Information

Patient Medical History

HIPAA Privacy Form

Patient Financial Responsibility Disclosure Statement


To request medical records to or from our clinic, please complete the form below:

Medical Records Request
Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery  Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery  Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery  Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery  Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery  Gary Bench MD, George Mueller, MD, Larry Pollack, MD, Mohan Krishnamoorthy, MD, Shawn Bench, MD, san diego, general surgery, bariatric surgery, plastic surgery
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