Make an Appointment
If someone else is the policy holder, please give their information below:
If yes, please give the following information to the best of your knowledge:
Have you been diagnosed or treated for any of the following conditions?
Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in
contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done
some of these things recently, try to work out how they would have affected you. Use the following scale to
mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)
BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ
AND AGREE WITH THE ABOVE OFFICE POLICIES.
As of January 1, 2002, the Dental Board of California now requires that we distribute to our
patients a copy of the Dental Materials Fact Sheet. In addition, the Health Insurance Portability
and Accountability Act (HIPPA) requires, effective April 14, 2003, that patients be given a copy
of our Notice of Privacy Practice.
If you would, please print and sign your name below.
I acknowledge I have received from this office:
Get available times and dates.
Hear what our patients have been saying.