Please complete and submit forms before appointment:  
Complete y envíe los formularios antes de la cita:

1. Patient insurance form
2. Medical history
3. Dental treatment consent
4. Financial policy agreement
5. HIPAA information
6. HIPAA acknowledgment

Extra Forms (if needed)

1. Covid 19 Patient screening (Please use doctor email: smileydoctor@gmail.com)
2. Address / Insurance update ( Please use this form if there is any update to address or insurance information)

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373 S Monroe St #203, San Jose, CA 95128

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Appointment:

Please take the appointment using here:  appointment at Smileydoctor San Jose

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You can pay using any below:

• Zelle: smileydoctor@gmail.com / 650-965-2929
• Venmo:  smileydoctor (Please give 4 digits as 2672 if venmo asks )
• Paypal : https://paypal.me/smileydoctor

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