Jonathon Everett Lee, D.D.S., Inc.

Brian D. Lee, D.D.S., M.S.D., Inc.

Christian P. Yee, D.D.S.

Diplomates of the American Board of Pediatric Dentistry
650.574.4447

Patient Forms

INSTRUCTIONS

Please click on the forms, print them and complete as needed. You will need Adobe Acrobat or Adobe Reader to open file.

Please fill out forms completely:

    If your appointment is within 3 days, please arrive at our office 15-20 minutes ahead of your scheduled appointment and bring your paperwork so we can process your paperwork and verify insurance coverage. Immediate paperwork submittal will aid in processing and verification of insurance coverage. You may also fax a copy of the paper work to our office at 650-574-4041.

    If your appointment is later, please mail back immediately, so we can process your paperwork and verify insurance coverage. Immediate paperwork submittal will aid in processing and verification of insurance coverage. Please also bring a copy of the paperwork in case there is a US Postal Service Delay.

New Patient Forms

Welcome Brochure >>Click For PDF

Health History Form* >>Click For PDF

For Patients With A Heart Condition or
A Significant Medical History:
Medical Consultation Request* >>Click For PDF

Privacy Practices Form >>Click For PDF
Privacy Practices Acknowledgement Form* >>Click For PDF

Dental Material Fact Sheet >>Click For PDF
Dental Material Acknowledgement Form* >>Click For PDF

Regarding Your Dental Insurance >>Click For PDF

For Patients who have been to a previous dentist:
Please fill out the Transfer Patient Form and send
to previous dentist.
Transfer Patient Form >>Click For PDF

For Patient Referrals:
Please fill out the Patient Referral Form and give
to patient.
Patient Referral Form >>Click For PDF

*Please bring completed forms to our office or you may fax them to us at: 650-574-4041.

Office Handouts

Nitrous Oxide >>Click For PDF

Oral Sedation Pre Operative Form >>Click For PDF

Oral Sedation Post Operative Form >>Click For PDF

Post Tooth Extraction Care >>Click For PDF

Boss of My Finger Chart >>Click For PDF
--Read our Blog About Oral Habits

Other Forms

Request for Exam or Cleaning and Fluoride Services Form
>>Click For PDF

*Please bring completed form(s) to our office or you may fax them to us at: 650-574-4041.