Register With Us

35513 S Highway 1 • Anchor Bay Village Gualala • Mendocino County • Emerald Triange Mile Marker 4.420 • PH 707.884.4420

Open Noon - 6pm (CLOSED SUNDAY & MONDAY& TUESDAY)

Pre-Registration From

Save time and pre-register with M.E.C.C.C.A. We must be able to:

1) reach you!

2)Verify that you have a CURRENT Doctors Recommendation

3)Verify that you are a current resident of the State of California

With all of the verification work out of the way, finalizing your registration on your first visit will be a breeze!

First Name: *
Last Name: *
Address 1: *
Address 2:
City: *
State: *
Zip: *
Mobile Phone:
Home Phone: *
Email Address: *
Date of Birth: *
Doctors Name: *
Doctors Phone Number: *
Doctors Fax #:
DOCTORS WEBSITE: *
PATIENT ID # (from Doctor): *
Date of Visit to Doctor:
Date Recommendation expires: *
CA Drivers Lic # (or ID #): *