Appointment Request Form
We aim to respond to you within 15 minutes during our business hours.  If possible, please take a photo of your referral slip and dental insurance card and send them to our phone number (626) 678-0167 after completing this form.  Our phone line is capable of messaging and receiving photos. 中文請發送簡訊 SMS 或 來電 (626) 678-0167.
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Email *
Phone number to reach you. *
Mobile number preferred so we can text you. Just the 9-digit numbers (i.e. no periods, parenthesis, spaces, symbols or dashes).
How would you like to be contacted? *
You will receive a response within 15 minutes during our business hours.  You can always text us at 626.678.0167.
Patient's Last Name *
Last name only
Patient's First Name *
First name only
Have you been given an appointment time already? Please enter it here.  If you don't have appointment time yet, please check "No appointment yet." *
Example: 1/15 at 2:30pm or check No appointment yet
Required
Patient's Zip Code (for insurance verification purposes) *
Patient's gender (for insurance verification purposes) *
Date of Birth for the patient *
MM
/
DD
/
YYYY
Please check all applicable items *
This will expedite and streamline your appointment scheduling with us.  We will also call your dentist on your behalf.
Required
Which offices is more convenient for you?  We see patients by appointments only.  Irvine office is currently closed due to COVID-19.
San Gabriel is opened Mon-Fri.  Irvine patient is encouraged to see Dr Yu in San Gabriel office..
Preferred appointment time.  We are usually open Mon-Friday 9:30am to 6pm. Any scheduling constrains?
Can you stay for treatment after consultation if there is time available?
Clear selection
Who is your general dentist? Name of the office and office number if readily available.
Please provide name and phone number in case we need to request additional information from you dentist.
What is the tooth number or area in question?
If the general dentist provide you with a blue referral slip, the tooth number and type of treatment is marked.  It will be a number (between 1 to 32.  Or, you can type in UR (upper right), UL (upper left), LL (Lower Left) or LR (Lower Right).
What type of treatment is marked on the referral slip?
Clear selection
Please provide dental insurance carrier name.  Otherwise please put "No insurance." *
Example: Delta Dental of Minnesota, DeltaCare USA. Unfortunately, we are not a Medi-Cal provider at this time.  
Is this a PPO, HMO, or other?
Clear selection
Group number, policy number and phone number.  If you don't know please provide social security number so we can look it up.
You can also text us a photo copy of your insurance card (front and back) at our office number 626.678.0167.
Are you the primary subscriber? If not, name of the subscriber and subscriber's date of birth.
If patient is a minor, please enter parent's/guardian's name and date of birth here.
Recent visit to dental office.  Date and type of procedure. (example: 8/11/20 Exam and cleaning)
Any additional information you wish to provide.  
Name and phone number of pharmacy, for example,  in case Dr. Yu needs to prescribe you medication.  Please state whether you are allergic to penicillin or any other medication.
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