Patient Registration Forms & Health History

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information.

Health History Form

Glendora Oral Surgery Online Registration form

Please download the free plug-in from Adobe’s web site if it is not already installed on your system.

On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Additional Forms

Please download the following forms and bring the completed and signed forms to your consultation appointment.


Please contact the office with any questions.

Glendora Office Phone Number 626-914-4587 Email Us

Our office is located at: 410 S. Glendora Avenue, Suite 220, Glendora, CA. 91741

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  • Office Hours: Monday thru Friday 8:00 AM until 4:30 PM
    Monday thru Thursday we schedule surgeries and consultations and on Friday’s surgeries only.