818-986-6223

Harry L. Dougherty Jr., D.D.S., M.S.

Sherman Oaks Medical Plaza
4955 Van Nuys Blvd., Suite 606
Sherman Oaks, CA 91403
818-986-6223

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Patient Forms

Please take a few minutes to print and fill out the patient information forms before your first appointment:

Privacy Authorization Forms [HIPPA.pdf]

Adult Patient Form [Adult%20HH.pdf]  [Adult%20Health%20History%20Form.doc]

Child Patient Form [Child%20HH.pdf]  [Child%20Health%20History%20Form.doc]

 

Additional forms are available for referring Doctors:

Guidelines For Adult Orthodontic Referral  [Guidelines%20for%20Adult%20Orthodontic%20Referral.pdf]

Transfer Patient In/Out Form  [AAO%20Transfer%20Form.pdf]  [Transfer%20Active.doc]

 **If you're unable to open PDF files, you can get Adobe ReaderĀ® for free.

 

 

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