562-698-2561
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.
Please do not use this form to cancel or change an existing appointment.
Please download the following forms and bring with you to your appointment, or email/fax back to us prior to your visit so that we may see you right on schedule.
1.
Welcome.pdf
2.
Patient Info 2016.pdf
3.
Health History 2016.pdf
4.
Dental History 2016.pdf
5.
FAMILY consent hippa.pdf
6.
Hippa.pdf
7.
Office Map.pdf
Items in
bold
are required.
Name:
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Yes
No
How did you hear about us?
Best time(s) to call?
Morning
Noon
Afternoon
Evening
Which office location(s) would you prefer for your appointment?
*
Whittier 9209 Colima Rd
Preferred day(s) of the week for an appointment?
Any Day
Monday
Tuesday
Thursday
Friday
Preferred time(s) for an appointment?
Any Time
Morning
Afternoon
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.