New Patient Form

  • General Information

  • Dental Insurance

  • Primary Dental Carrier
  • Secondary Dental Carrier
  • Health History

  • Women:
  • Dental History

  • On a scale of 1-10, with 10 being the highest rating:
  • Office Policy

  • NO SHOW AND CANCELLATION
    In order to continue providing excellent quality, yet affordable dental services, it is important for our patients to understand that appointments are reserved for you in advance; please make effort to keep your appointments. Please notify us within 48 hours if you need to cancel your appointment. In the event of a No Show or Cancellation without 48 hours’ notice, you will be required to pay a $50 Reschedule Fee before being placed back on the schedule, $25 of which can be used for future services.

    A $250 deposit will be required to reserve an appointment for your surgery date. This fee will be applied to dental work that is scheduled to be done.

    PATIENTS WITH DENTAL INSURANCE
    It is your responsibility to provide our office with your dental plan and to let us know of any changes at your appointment. We will continue to try and help you understand your policy but please be aware that there are thousands of different policies and we do not know all of the limitations for all of the plans out there. If for any reason your insurance company does not pay for a procedure, the balance is your responsibility to pay in full upon receipt of the statement.

    I AM RESPONSIBLE FOR MY BALANCE IF ANY OF THE FOLLOWING OCCUR:

    ● The treatment goes over my yearly maximum.
    ● Any treatment that is denied by my insurance company.
    ● I am not eligible for insurance.
    ● I prevent or delay by not complying with requests for insurance forms or signatures.
    ● I do not complete my treatment and it results in non-payment by the insurance company.
    ● Lab and equipment costs that incurred due to a missed appointment.
    ● I received my insurance check and do not send it to the office.

    By signing this, I have read and understand the above policy.
  • Consent for Treatment

  • I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough, diagnosis of patient's dental needs.

    Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and the employ such assistance as required to provide proper care.

    I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

    I give consent to the doctor’s or designated staff to use and disclosure of any oral written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and healthcare operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protections of my personal health information is available.

    I agree to be responsible for payment of all services rendered on my behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

  • HIPPA Release of Information

23961 Calle De La Magdalena #102

Laguna Hills, CA 92653

(949) 586-6030

Call us today!

Opening Hours

Mon - Thurs: 8:00 - 5:00

Appointment Booking

Click Here to Book
Call Now!