562.92.SMILE

Patient Forms

Please take a few minutes to print and fill out the patient information form before your first appointment.

  • Patient Registration Form   [PDF]
  • Medical History Exam   [PDF]
  • HIPAA Authorization   [PDF]
  • HIPAA Notice of Privacy Practices   [PDF]
9818 Paramount Blvd., Suite A, Downey, CA 90240  |  562.92.SMILE – 562.927.6453  |  Fax 562 927-3400

Diplomate,
American Board of
Pediatric Dentistry

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