Patient Forms

NEW PATIENT REGISTRATION



ONLINE FORMS:

Please complete these forms accurately and completely. Your submitted information is 100% secure and confidential through our HIPAA compliant service portal. When you are done, just click the "Submit" button, and you have completed the first step on your way to a healthier and more attractive smile!

ONLINE New Patient Registration

ONLINE Notice of Privacy Act Acknowledgement

ONLINE Office Policy Acknowledgement

DOWNLOADABLE FORMS

Another way is to download and fill out the following forms before your first visit at our office.  You can email us the completed forms at coastlinesmiles@gmail.com or print them out and bring them with you to your scheduled appointment.  During this time, you will get acquainted with Dr. Nguyen and our wonderful staff and learn about your possible treatment need.

New Patient Registration

Notice of Privacy Act Acknowledgement

Office Policy Acknowledgement



 

PEDIATRIC MEDICAL & DENTAL HISTORY

 

Please complete this form prior to your child's next check-up appointment and inform us of any recent change in the patient's health.

PEDIATRIC MEDICAL DENTAL HISTORY UPDATE




   

COVID-19 PATIENT SCREENING


We ask that our patients fill out the following form prior to your appointment with us to monitor any symptoms before and on the day of the appointment. We just want to make sure that everyone is safe. 

A parent or guardian will also need to complete the screening forms if you wish to come into the office with the patients.

COVID-19 CREENING FORM. To be completed on the day of the appointment when you arrive at the office.