Patient Forms

For your convenience, prior to visiting our office, please click on the links below to view and print the New Patient Forms, complete the information, and bring them with you to your first visit.

(To print the forms you will need Adobe Acrobat Reader. If you do not have Adobe Acrobat, please download the free Acrobat Reader from Adobe's web site if it is not already installed on your system.)

New Patient Registration Form
Notice of Privacy Practices
Insurance Form (For Delta Dental Patients Only)
Financial Policy Form
Release of Records Form

Dental Website Design by PBHS 2010©

Doctors Neil M. Katsura, Bob A. Khalil, Arnold H. Nakazato, Ameneh Khosrovani, Carole Miyahara, Megan Golinveaux
and Joseph K. Wampler are pediatric dentists in Berkeley, CA, specializing in the treatment of infants, children
and adolescents in the San Francisco East Bay Area cities of Berkeley, North Berkeley and Orinda.

3010 Colby St., #217, Berkeley, CA 94705 • Phone: (510) 848-6494 • Fax: (510) 848-9329
2640 Telegraph Ave. Suite 101 Berkeley 94704 • Phone: (510) 848-6494 • Fax: (510) 981-1159
906 Ensenada Ave., North Berkeley, CA 94707 • Phone: (510) 528-1546 • Fax: (510) 528-4362
3 Altarinda Rd., Suite 210, Orinda, CA 94563 • Phone: (925) 253-8190 • Fax: (925) 253-8199