online patient forms

All downloadable files are in PDF format. PDF documents retain the original formatting regardless of computer platform or Internet browser.

To view and print PDF files, you will need Acrobat^® Reader^®. You may already have it installed. If not, you can download it directly from Adobe^® by clicking on the icon below.

Patient Forms

Patient Information Form

	Instructions:
	1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
	2.	Print the form and complete it prior to your appointment.
	3.	Present the completed form to our front office staff at your dental appointment.

Description:

The Patient Information form must be completed by all new patients. If you are an existing patient, you do not need to update this form unless your last visit to our office has been over 1 (one) year.

Completing this form prior to your appointment will alleviate the need to complete it at our office. This will help us better serve you and provide Dr. Wong with more time to provide excellent dental care.

The following information is requested on the form. Please complete all sections to the best of your ability. If you have any questions, please feel free to contact us.

- Patient & Contact Information

- Dental Insurance Information (if applicable)

- Health History (Dental & Medical)

- Medications & Allergies

- Acknowledgement: Receipt of Dental Materials Fact Sheet

- Acknowledgement: Receipt of Notice of Privacy Practices

Note:

Click on the icon to view and print copies of these documents.

Dental Treatment Consent Form

	Instructions:
	1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
	2.	Print the form and complete it prior to your appointment.
	3.	Present the completed form to our front office staff at your dental appointment.

Description:

The Dental Treatment Consent form outlines the benefits, risks, and alternatives associated with dental procedures. Signing this form acknowledges you have read and understand all the information provided.

The Dental Treatment Consent form must be signed and submitted to our front office staff prior to receiving dental treatment such as extractions, fillings, crowns, bridges, root canals, periodontal cleaning, and dentures/partials. This form is not required for consultations, exams, and/or general cleanings.

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Patricia M. Wong, DDS \| 1530 Judah Street \| San Francisco, CA 94122 \| (415) 759-8680 \| All Rights Reserved 2003-2008