New Patient Form Fill out our digital intake form before your first visit; saving you from having to fill it out in person. Please enable JavaScript in your browser to complete this form.1Patient Info2Dental Info3Medical Info4Appointments & Costs5HIPPA Consent6Patient ConsentPatient InformationName *FirstLastEmail *Mobile Phone *AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryP.O. box addresses are not acceptableDate of Birth *Social Security Number *Drivers License NumberIf you live within the United StatesState IssuedAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGender *MaleFemaleNon-BinaryMarital Status *SingleMarriedDivorcedWidowedHow did you hear about/find us? *What is your Instagram handle?Responsible Party Information Only fill out this section if you are not the patient but rather the responsible party. (i.e. the parent of a child)NameFirstLastEmailMobile PhoneAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryP.O. box addresses are not acceptableDate of BirthSocial Security NumberDrivers License NumberIf you live within the United StatesState IssuedAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGenderMaleFemaleNon-BinaryMarital StatusSingleMarriedDivorcedWidowedInsurance InformationName of InsuredFirstLastInsured Social Security #Date of BirthRelationship to InsuredSelfSpouseChildOtherEMPLOYER INFORMATIONEmployer NameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone NumberInsurance or Employee IDINSURANCE COMPANY INFORMATIONInsurance Company NamePhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI hereby authorize assignment of my insurance benefits directly to the provider for services rendered. I fully understand am solely responsible for any balance not paid by my insurance company.Insurance Company Payment Responsiblity *I AgreeEmergency ContactName *FirstLastMobile Phone *Relationship to Patient *AuntBrotherCousinFatherFriendGrandfatherGrandmotherGuardianMotherNeighborSisterUncleNextDental InformationHave you ever had a bad experience at a dental office? *YesNoPlease explain your bad experience *How would you describe your current dental problem? *Date of last dental exam *Name of Previous DentistPhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you have/do/want any of the following?Bad breathBleeding gumsClenching or grindingFloss once a dayFood ImpactingMouth breathingNervousPain around earPeriodontal treatmentPlay sportsSmokeSnoreStraighter teethSwelling or lumpsTeeth sensitive to cold or heatTeeth sensitive to sweetsUnpleasant tasteWhiter teethCheck all that apply.NextMedical InformationDo you have any of the following:AIDS / HIV PositiveAlzheimer’s DiseaseAnemiaAnginaArthritis/ GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold SoresCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting/ Dizzy SpellsFrequent CoughFrequent DiarrheaFrequent HeadachesG.I. DiseaseGenital HerpesGlaucomaHay FeverHeart attackHeart MurmurHeart Pace MakerHeart TroubleHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHives or RashHypoglycemiaIrregular Heart BeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentRecent Weight LossRetinal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpinal BifidaStrokeSwelling of the LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow JaundiceDo you/are you?Do you take or have you taken Phen-Fen or Redux? *YesNoDo you use tobacco? *YesNoAre you on a special diet? *YesNoDo you use controlled substances? *YesNoAre you pregnant/trying to get pregnant? *YesNoI'm a maleAre you nursing? *YesNoI am maleTaking oral contraceptives? *YesNoI am maleAny other serious illness not listed?Are you allergic to any of the following:AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOtherWhat else are you allergic to? *Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Are you under a physician’s care now, or have been in the past 2 years? *YesNoWhy are/were you under the care of physician? *Physician's Name *Phone *Have you been hospitalized or had a major operation in the past 5 years? *YesNoPlease explain *Have you ever had a serious head or neck injury? *YesNoPlease explain *Are you currently taking any medications, pills or drugs? *YesNoThird ChoiceWhat are you taking? *To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in the condition of my health or if my medications change, I will, without fail, inform the doctor at my next appointment.Signature *Clear SignatureNextAppointments and CostsAs a courtesy, we attempt to confirm most appointments 48 hours in advance. However, if we are unable to reach you, keeping your appointment is your responsibility.48 Hour Advance Notice *I AgreeWe require an advanced 24 hour notice of cancellation or request to reschedule an appointment.24 Hour Notice *I AgreeFailure to reschedule or cancel your appointment in this time frame will result in a charge of $50 per 1/2 hour appointment(s) for general and $100 per 1/2 hour appointment(s) with specialists. Please note that all Monday appointments shall be canceled by 5 P.M. Friday or a broken appointment charge will be applied.Failure to Reschedule *I AgreeAs a condition of treatment by this office, financial arrangements must be made in advance. We depend upon timely reimbursement for the costs incurred in rendering care. Financial responsibility on the part of each patient must be determined before treatment.Financial Resposibility *I AgreeAll emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.Emergency Dental Services In Cash *I AgreePatients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any insurance payment to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.Dental Insurance *I AgreeA service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements are satisfied.Service Charge *I AgreeI understand that any fee estimate for dental care can only be extended for period of six months from the date of the patient examination.Fee Estimate *I AgreeIn consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of time or condition hereunder shall not constitute a waiver of any other term or condition and I further agree as the responsible party to pay all costs including but not limited to outside collection fees, bank fee, penalties and reasonable attorney fees.Pay at Time of Treatment *I AgreeI grant permission to you or your assignee, to telephone me to discuss this statement or my treatment.Signature *Clear SignatureNextHIPPA ConsentI give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies and for health care operations like quality reviews. I have been informed that I may review the practices Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, excluding any for information already used or disclosed.Signature *Clear SignatureNextPatient ConsentWith miracles of modern dentistry, we can restore function, aesthetics and comfort to the oral structures, by providing state of the art dental treatment to our patients. Dental treatments are usually successful with excellent outcomes. However, since dentistry is not an exact science, and there are variations in patients' physiological response to dental treatments, in remote occasions complications may occur.Complications *I UnderstandWe are trained and equipped to handle most complications. In case of problems with dental restorations, they will be repaired or replaced for a period of one year without charge to the patient. It is our moral and legal duty to inform our patients of the possibility of complications however unusual and remote they may be.Dental Restorations *I UnderstandDental Material Fact Sheet I have received a copy of the Dental Material Fact Sheet, Prepared by the California Dental Board and provided to me by this office.Dental Fact Sheet *I AgreeLanguage In reading and signing this form, it is understood that ENGLISH is the language that I understand and use to communicate. Otherwise, this document has been translated to me and I fully understand its content.Language *I AgreeChange in Treatment Plan I understand that due to changing conditions, it may be necessary to change or add procedures, due to new findings not present during the initial examination and treatment planning or changes in the priorities of the treatment sequences. I understand that I will be informed of these changes before the initiation of the clinical procedures.Change in Treatment Plan *I AgreeRadiographs (X-rays) I have been advised, and consent to the following: I am to receive a full mouth series of X-RAYS every five years or when in the judgment of the doctor, it is necessary. This series of radiographs will provide diagnostic information and documentation for my teeth and surrounding oral tissues. I will receive periodic examination and X-rays for the correct and accurate diagnosis of my oral condition. I will consent to diagnostic X-rays at a frequency as assessed by the doctor. I understand that all reasonable precautions will be taken to minimize my exposure to unnecessary radiation. Radiographs (X-rays) *I AgreeI have read the above statements and have received a copy of them if requested, and recognize their importance in helping me make decisions. My initials indicate that I have read and understand this consent document. recognize that failures can occur for all kinds of reasons and that complications can occur in any procedure. I also understand that, where decay has occurred, or tooth has fractured or abscessed, that these same forces are still working on the tooth even after it has been restored: therefore, decay or fracture can still occur as the restored tooth is no better than what nature has given in the first place. If for any reason a conflict or disagreement should arise will first present such conflict or disagreement to my attending dentist in order to resolve the problem. If we are unable to agree on a solution, then agree to take the problem to a reconciliation / mediation board such as the dental society and agree to accept their resolution in lieu of pursuing remedies by way of litigation. Also understand that this agreement is binding on my heirs and all other family members. Now give my consent to the attending dentist to render to me the dental treatment that we have agreed is necessary I also agree to reimburse the attending dentist for all services rendered to me and I am aware that the payment for these services is due at the time they are rendered.Signature *Clear SignatureSubmit