Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

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Patient Forms

Hippa Form Page 1 Hippa Form Page 2

(Print & Complete All Forms Prior To First Office Visit)


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Bellflower, California

16505 Clark Ave, Bellflower, California 90706

Email: samcosmeticdentistry@aol.com

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Office Hours

  • Monday7:00 am - 3:00 pm
  • Tuesday8:00 am - 1:00 pm, 2:00 pm - 6:00 pm
  • Wednesday8:00 am - 1:00 pm, 2:00 pm - 6:00 pm
  • Thursday9:00 am - 5:00 pm
  • Friday7:00 am - 12:00 pm
  • Saturday7:00 am - 1:00 pm
  • SundayClosed
562.925.2223