ACCESSIBILITY Accessibility

Patient forms

NEW PATIENT REGISTRATION

1) ONLINE FORMS: Please complete this required online New patient registration and Notice of Privacy Act Acknowledgement form 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

2) 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 sjdentalspecialists@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.


PEDIATRIC MEDICAL-DENTAL HISTORY UPDATE

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 forms prior to your appointment with us. They are both quite similar, for this reason we hope that you understand the redundancy, but the forms are important 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.

1. PRE-SCREENING FORM. To be completed at the time you make an appointment with us or before you come to the office

2. IN-OFFICE SCREENING FORM. To be completed on the day of the appointment when you arrive at the office.


Office Location

  • San Jose
  • 1569 Lexann Ave, #222
  • San Jose, California
  • 95121
  • Map & Directions
  • Call: (408) 600-3200