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John M. Moffat, DDS
Creating Beautiful Smiles
Call: (818) 225-0041

Patient Forms

New Patient Registration Forms (or if you are changing your payment arrangements.)Thank you for taking the time to fill out our New Patient Registration forms.  Please allow 15 to 20 minutes to read and fill out the forms listed below.  We hope this will save you time and add to your experience at our office. Please print and fill out a copy of the Health History Form to bring to the office upon your first visit.  Also, please read our Notice of Privacy Practices and the Dental Materials Fact Sheet, then print and sign the 'Acknowledgment' page verifying that you have read these notices, and bring this to the office as well. Again, we thank you and are excited to see you soon.                                                                                                                           

Health History Form (fill out and bring to the office on your first visit)                                  

Notice of Privacy Practices (read, English / Spanish)

Board of California's Dental Materials Fact Sheet (read, English / Spanish)

Acknowledgment of Receipt of Notices (sign and bring to the office)

Lastly, please print and fill out a copy of the Financial Arrangements form, the Release and Assignment form, and the Consent to Release information form to bring to the office.

Financial Arrangements (fill out and bring to the office)
Release and Assignment  (bring to the office, then sign at office once we give you more information)
Consent to Release Information (fill out and bring to the office, English / Spanish)

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