323-445-9944
FORMS
HEALTH HISTORY
No patient is seen without a current health history, the form is provided here.
Note: current medications, vitamins, and supplements lists can often be printed out by nursing home staff. Please forward patients most current dental x-rays to our email.
PATIENT INFO
The patient information form is necessary to reach patients and their support team, as well as to submit insurance claims as a courtesy facilitating patient reimbursement by their carrier. Form is here.
REFERRAL SLIP
Are you a healthcare provider who wants to refer a patient to us? Use this referral slip.
Note to healthcare professionals: please indicate in your referral if you will conduct dental exams yourself or provide restorative care yourself.
*STANDING ORDER*
Patients must provide an annual standing order from a dentist or primary care physician to continue dental hygiene services. At minimum, the following text shall be written on a doctors note letterhead: This is a standing order permitting [patient name] to have dental hygiene services provided on-site by Danielle Lowery, RDHAP with antibiotic premedication coverage and application of topical fluoride varnish as needed. Note to healthcare professionals: please indicate in your standing order whether you want to conduct dental exams yourself or provide restorative care yourself.