Save time at check-in by completing your paperwork before your visit. Choose the option that's easiest for you.
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Fill out online — securely
Book online in a couple of minutes and your intake forms are emailed to you to complete from your phone or computer. Your health information stays protected.
Prefer paper? Print the forms below, complete them at home, and bring them to your appointment. Or call 818.890.1000 and we'll have them ready for you.
Please don't email medical details.For your privacy, never send health information through regular email or our contact form. Use the secure online forms or bring paper forms to the office.
San Fernando Pacoima Family Dental 11208 Glenoaks Blvd, Pacoima, CA 91331 · 818.890.1000
1. Medical History Form
Helps us treat you safely.
Patient name
Date of birth
Physician's name
Physician's phone
Current medications (include vitamins & supplements)
Allergies (medications, latex, foods)
Do you have, or have you had, any of the following?
I acknowledge that I have been offered a copy of the Notice of Privacy Practices of San Fernando Pacoima Family Dental, which describes how my health information may be used and disclosed and how I can access it.
You may contact me for appointment reminders by:
Phone callText messageEmailVoicemail at home
People we may discuss your care with (name & relationship)
Patient / guardian signature
Date
Printed name
Relationship (if guardian)
Forms done? Let's get you scheduled.
Request an appointment online or give us a call. Hablamos Español.
