Patient Forms

New Patient? Please print and fill out the following forms and bring them with you to your first appointment to expedite your visit. 

Health History Form
Mandatory medical history form for all patients
ADA Health History Form.pdf
Adobe Acrobat document [1.4 MB]
Handle Me With Care Form
Share your preferences so we can better handle you with care
Handle Me With Care Form.pdf
Adobe Acrobat document [78.2 KB]

Additional Resources

The following documents contain important information regarding our privacy policy and dental materials. Please read over them and keep copies for your records.

Notice of Privacy Practice
Please read and acknowledge our privacy policy
HIPAA Notice of Privacy Practice.pdf
Adobe Acrobat document [427.1 KB]
Dental Materials Fact Sheet
Important information from the Dental Board of California
DBC Dental Materials Fact Sheet.pdf
Adobe Acrobat document [481.5 KB]
Free Habit Tracker
Keep track of daily habits that help maintain healthy smiles!
Atienza Family Dental - Habit Tracker.pd[...]
Adobe Acrobat document [2.5 MB]

To learn more, visit:

Regis Atienza D.M.D.
Annabelle Atienza D.M.D.

Office Hours

Monday: 8 AM - 6:30 PM
Tuesday: 8 AM - 6:30 PM
Wednesday: 8 AM - 6:30 PM
Thursday: 8 AM - 6:30 PM
Friday: Closed

Office Contact

Call: (209) 594 - 1119
Text: (209) 405 - 3190
Fax: (209) 594 - 1740
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© Atienza Family Dental