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New Patient Forms

New Patient Registration

To make your visit to our lodi family practice as convenient as possible, below are new patient registration forms .You can print a copy at home and fill in the information at your convenience. Then just bring the completed forms with you to the clinic for your appointment. Please read the Notice of Privacy Practices before you sign Consent .

NEW PATIENT REGISTRATION AND HISTORY FORM

Microsoft Word document (.doc)
Adobe Acrobat document (.pdf)

NOTICE OF PRIVACY PRACTICES

Adobe Acrobat document (.pdf)

OTHER FORMS:

PATIENT RECORD RELEASE AUTHORIZATION FORM

Microsoft Word document (.doc)
Adobe Acrobat document (.pdf)

Technical Note:You need Adobe Acrobat Reader to view some of our form. Please download it from Adobe's web site if it is not already installed on your system

Lodi Dentist providing the professional services .Dr. Mary ali is a well-trained Lodi Dentist providing the complete dental services to Lodi Ca community include Teeth cleaning | teeth whitening |children Dentistry| cosmetic dentistry | Oral Hygiene instructions | Complete Dental Exam | Digital X-Rays | Fluoride Treatment |Sealants | Amalgam fillings | Composite white Fillings | dental Crowns | Fixed Dental Bridges | Veneers | Periodontal Disease | Dental Implants | Restorations | Dentures complete and Partial | Root Canal Therapy | night guards | Extractions | denture repairs | Periodontal Treatment, Porcelain Crowns and much more.

Contact Us

Send Us An Email Today! We'll Provide You With That Winning Smile!

Our Location

525 South Fairmont Avenue, Suite H, Lodi, CA 95240

Hours Of Operation

We look forward to hearing from you.

Monday:

8:00 AM-5:00 pm

Tuesday:

8:00 AM-5:00 pm

Wednesday:

8:00 AM-5:00 pm

Thursday:

8:00 AM-5:00 pm

Friday:

8:00 AM-5:00 pm

Saturday:

Closed

Sunday:

Closed