Electronic Records Consent

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Completing patient forms can be timely and frustrating. We have streamlined the entire process into the form of a questionnaire. It reduces the burden on new patients and enables our clinical and administrative staff to better prepare for your first visit. Checking in for a first appointment is quicker and easier.

Name

First

Middle

Last

Our questionnaire consists of five (5) documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed a document, simply click the submit button to proceed.

The information you submit is encrypted for your protection and goes directly to our office. Your information remains confidential. No third-party receives or has access to the information you provide us.

If you have any questions or need assistance, please contact our administrative staff at (858) 249-4441or by email at office@sandiegodentalhealthcenter.com.

Consent to use Electronic Records and Signatures

I consent to use Electronic Records and Signatures. Electronic Signatures and Records Disclosure

Signature

Please draw your signature in the box. Use the X to clear your signature.

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