The following forms may be downloaded and printed.  If you have difficulty downloading or printing the forms, please let us know.  We can send them by email, fax or by US Postal Service.


Patient Registration Form

Patient Registration Form.doc Patient Registration Form (.doc)

Patient Registration Form

Patient Registration Form.pdf Patient Registration Form (.pdf)

 

Patient Consent to Treatment

Patient Consent to Treatment.doc Patient Consent to Treatment (.doc)

Patient Consent to Treatment

Patient Consent to Treatment.pdf Patient Consent to Treatment (.pdf)

 

Medical and Dental History

Patient History.pdf Patient Medical and Dental History (.pdf)

 


The following forms are ones we frequently provide for our patients or are signs posted in our office.  They are here for you to open and use for your information or as needed.  If you have any questions about the content of these forms, please call us at (818) 225-7744.


Health Information Portability and Accountability Act

HIPAA Notice.pdf HIPAA Form (.pdf)

 

Dental Materials Fact Sheet

DMFS2004.pdf This form should be printed under landscape setting, 2-sided, flipped along the short edge to create an 8 page pamphlet.

 

Dental Record Release Authorization

Dental Record Release Authorization.doc This form is to complete and submit to your previous dentist to release any requested records to us.

 

Postoperative Instructions

Postoperative Instructions.doc Instructions to follow after extractions or root canal treatment.

 

Care for Temporomandibular Joint Disorder

Care instructions for TMD.doc Patient Care for TMD

 

Denture Care Instructions

Denture Care Instructions.doc How to take care of dentures.