These forms are an electronic copy
of our New Patient Questionnaire, which we use to gather your personal
information. It should take just a few minutes to complete. Fill it
out by using the [TAB] key between data fields.
If you are using Adobe Acrobat 6.0 Standard or
Professional version; after you complete the form click "SUBMIT" at the bottom of the
form, and when the e-mail window appears click "SEND" and the form will be
e-mailed
to our Cerritos office. If you are using just the Adobe Reader (see bottom
of this page for free download) you will not be able to e-mail the form and you
should click on the PRINT icon at the top of the Adobe Reader to print the form
and either fax, mail or bring it to our office. Our staff will begin
to process you as a new patient, so your first visit will have more time devoted
to your dental care, and less time completing paperwork required by our offices.
Fill out only as much as you can or wish; the missing information will be asked
when you visit our offices.
A member of our office staff will contact you when
we have received the form.
Thank You for choosing us as your dental provider. Please complete all information in-full for each patient (adult or child or both) so we may better serve you. All information is kept CONFIDENTIAL.
Please select the appropriate form from below. One form is required per patient. If you need to use more than one form for multiple patients, complete the first form and either print it or e-mail it and then click your back button to select another form.
To use these forms and have the ability
to print them after filling them out, you must have the
most recent Adobe Reader installed on your computer. For free download or
upgrade click on the icon below. Remember: With the Adobe Reader you
will not be able to e-mail the forms but you will have the capability to print
them by clicking on the PRINT icon at the top of the Adobe Reader and after
printing either
fax, mail or bring them to our office.