Patient forms
Save time at check-in: fill out your forms on your computer or print them, then email them to afsounasgharzadehdds@gmail.com or bring them to your visit.
Forms for your visit
New patients, please complete all four forms. Returning patients only need to update the forms if something has changed.
New Patient Registration
Your contact details, emergency contact, responsible party and PPO insurance (primary and secondary). PDF, 2 pages.
Medical & Dental History
Health conditions, medications, allergies, dental history and anything that makes you nervous about dental care. PDF, 2 pages.
HIPAA Notice Acknowledgment
Confirms you received our privacy notice and tells us how you'd like us to contact you. PDF, 1 page.
Financial Policy & Consent
Insurance, payment, our 24-hour cancellation policy and your consent to treatment. PDF, 1 page.
How to complete your forms
- Download each form. Fillable fields work in Adobe Acrobat Reader (free), Apple Preview and most web browsers.
- Fill it out on your computer and save it, or print it and complete it by hand.
- Sign and date each form where shown. You can type your name in the signature field or sign the printed page.
- Send it to us: email the completed forms to afsounasgharzadehdds@gmail.com before your appointment, or bring them with you.
A note on privacy: regular email isn't a fully secure channel. If you'd rather not send health information by email, bring your completed forms to your visit. Please don't send forms through the appointment request form on our website.
Our privacy notice
Our Notice of Privacy Practices (PDF) explains how we use and protect your health information and your rights under HIPAA. A printed copy is available at the front desk on request.
Questions about a form? Call (310) 829-4322 and we'll be glad to help.