accessibility ACCESSIBILITY

Patient/Provider Forms

If you are a new patient to our practice, the attached forms are available for you to fill out in advance of your scheduled appointment at our office.  Printing them, filling them out and bringing them with you will allow us to attend to your oral health care needs more quickly than completing them upon your arrival.  Thank you and please call our office at (909) 558-4960 if you have any questions at all.

Patient Forms

New Patient Welcome Letter

New Patient Registration Form

Release of Patient PHI Authorization Form

Medical History Questionnaire

Smile Analysis Questionnaire

Financial Policy - Patients With Insurance

Financial Policy - Patients Without Insurance

Financial Policy - Patients With Risk Management Insurance

Ortho New Patient Form

Pediatric Health History Questionnaire

FDO - Risk Management Summary of Benefits

CareCredit - credit application form

TMJ/Sleep Apnea Patient Forms 

Orofacial Pain Health History Form

Orofacial Pain Evaluation Form

Sleep Apnea Questionnaire

TMJ Questionnaire

Provider Forms

Faculty Dental Office referral

Request for Patient Records

 

This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.