Call: (408) 223-7414

Patient Forms

You may access the following forms to assist us with your care. Please complete the following forms, and click the "Submit" button at the bottom of each form. 

Child New Patient Information

Adult New Patient Information 

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

 

Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.

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Office Location

  • San Jose
  • Teresita L Dizon DMD INC
  • 2690 S White Rd #90
  • San Jose, California
  • 95148
  • Map & Directions
  • Call: (408) 223-7414