Call to Make An Appointment
408.268.4161
6541 Crown Blvd, Suite G
San Jose, CA 95120

Patient Forms

We understand that most of you have extremely busy schedules during the week and want your visit to the dentist to be as painless and quick as possible. To help you be in and out of the dentists chair we have put all our patient forms online.
If you are a new patient visiting the practice you can fill these patient forms online in the comfort of your home and click the submit button once you are done. These forms will be donwloaded securely onto our server and we will have them ready for your signature at your first appointment. Below you will find forms for patients who are 14 years or older of age and for patients who are less than 14 years of age. If you and a child will be visiting, please make sure you submit one set of forms for yourself and one for your child.

1. For Patients 14 years or older of age
These forms are required before we can start any dental treatment. They cover important information about you, emergency contacts, insurance carrier information and previous dental and medical history. Please complete the patient registration form, health history form, patient office agreement form and HIPAA form. (This form is an acknowledgement of how we will protect the confidentiality of your personal health information according to Federal Law (HIPAA – Health Insurance Portability and Accountability Act).
Please fill out all the forms and check for accuracy before you press the submit button. We look forward to seeing you at your first appointment (please click here to fill out the forms)

2. For Patients less than 14 years of age
These forms are required before we can start any dental treatment. They cover important information about you, emergency contacts, insurance carrier information and previous dental and medical history. Please complete the patient registration form, health history form, patient office agreement form and HIPAA form. (This form is an acknowledgement of how we will protect the confidentiality of your personal health information according to Federal Law (HIPAA – Health Insurance Portability and Accountability Act).
Please fill out all the forms and check for accuracy before you press the submit button. We look forward to seeing you at your first appointment (please click here to fill out the forms)