Skip to content
New Patients Only
(310) 737-8787
Existing Patients Only
(310) 276-4537
Rated Among Best Cosmetic Dentistry in Beverly Hills
New Patients Only: (310) 737-8787
Existing Patients: (310) 276-4537
Cosmetic Dentist
Smile Makeover
Porcelain Veneers
Lumineers
Dental Bonding
Laser Dentistry
Porcelain Fillings
Teeth Whitening
Face Lift Surgery
TMJ Dentist
TMJ Treatment
Tmj Treatment Without Surgery
TMJ Symptoms
TMJ Causes
The Dangers Of Untreated Tmj
Orthodontics
Invisalign
Neuro Muscular Orthodontics
Bite Correction
Zone Mouthguard
Clench Relief™
General Dentist
Dental Implants
Full Mouth Rehabilitation
Root Canal
Sleep Apnea Treatment
Sleep Dentistry
Periodontal Treatment
Worker’s Compentation Dentist
Our Dentistry
About us
Meet Our Team
Testimonials
Celebrity Smiles
Before And After
Press
Technology
Blog
Office Locations
London Office
Office Tour
FAQ
Fly-in
Financial Options
Virtual Smile Preview
Contact Us
Text Us
New Patient Special
Cosmetic Dentist
Smile Makeover
Porcelain Veneers
Lumineers
Dental Bonding
Laser Dentistry
Porcelain Fillings
Teeth Whitening
Face Lift Surgery
TMJ Dentist
TMJ Treatment
Tmj Treatment Without Surgery
TMJ Symptoms
TMJ Causes
The Dangers Of Untreated Tmj
Orthodontics
Invisalign
Neuro Muscular Orthodontics
Bite Correction
Zone Mouthguard
Clench Relief™
General Dentist
Dental Implants
Full Mouth Rehabilitation
Root Canal
Sleep Apnea Treatment
Sleep Dentistry
Periodontal Treatment
Worker’s Compentation Dentist
Our Dentistry
About us
Meet Our Team
Testimonials
Celebrity Smiles
Before And After
Press
Technology
Blog
Office Locations
London Office
Office Tour
FAQ
Fly-in
Financial Options
Virtual Smile Preview
Contact Us
Text Us
New Patient Special
Book an appointment
Book Consultation
Disclaimer
Please wait while the policy is loaded. If it does not load, please
click here
to view the policy.
Step
1
of
6
16%
Personal Information
Full Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Contact Information
Phone
(Required)
Email
(Required)
Preferred Contact Method
(Required)
Phone
Email
Text
Workers’ Compensation Information
Claim Number
Date
MM slash DD slash YYYY
Workers’ Compensation Insurance Provider
Name
Contact
Adjuster
Name
Contact
Attorney
Name (if applicable)
Contact (if applicable)
Injury Details
Description of Injury (Body part, type of injury)
Are any teeth damaged?
Yes
No
If yes, please specify
Are you experiencing any TMJ (jaw) symptoms? (e.g., jaw pain, clicking, difficulty opening mouth)
Medical History
Any prior related injuries or conditions?
Yes
No
Current Medications
Current Symptoms & Limitations
Describe your symptoms (pain, numbness, etc.)
Any physical limitations (e.g., difficulty walking, lifting)
Appointment Preferences
Preferred Appointment Date & Time
Authorization & Consent
Consent to release medical records
Yes
No
Consent to communicate with insurance company
Yes
No
Untitled
(Required)
I allow Perfect White Smile to contact us through text message
CAPTCHA
This field is hidden when viewing the form
Site Name
This field is hidden when viewing the form
Site Phone
X
First Name
Last Name
Phone
(Required)
Email
(Required)
Workers Compensation Insurance carrier and adjustment information
Carrier Name
Adjuster Name
Phone
(Required)
Email
(Required)
Attorney
Date
(Required)
MM slash DD slash YYYY
Symptoms
Untitled
(Required)
I allow Perfect White Smile to contact us through text message
CAPTCHA
This field is hidden when viewing the form
Site Name
This field is hidden when viewing the form
Site Phone
X
call or text us
New Patients
(310) 737-8787
Existing Patients
(310) 276-4537
Cosmetic Dentist
Smile Makeover
Porcelain Veneers
Lumineers
Dental Bonding
Laser Dentistry
Porcelain Fillings
Teeth Whitening
Face Lift Surgery
TMJ Dentist
TMJ Treatment
Tmj Treatment Without Surgery
TMJ Symptoms
TMJ Causes
The Dangers Of Untreated Tmj
Orthodontics
Invisalign
Neuro Muscular Orthodontics
Bite Correction
Zone Mouthguard
Clench Relief™
General Dentist
Dental Implants
Full Mouth Rehabilitation
Root Canal
Sleep Apnea Treatment
Sleep Dentistry
Periodontal Treatment
Worker’s Compentation Dentist
Our Dentistry
About us
Meet Our Team
Testimonials
Celebrity Smiles
Before And After
Press
Technology
Blog
Office Locations
London Office
Office Tour
FAQ
Fly-in
Financial Options
Virtual Smile Preview
Contact Us
Text Us
New Patient Special
Instagram
Youtube
Facebook
First Name
Last Name
Phone
(Required)
Email
(Required)
Workers Compensation Insurance carrier and adjustment information
Carrier Name
Adjuster Name
Phone
(Required)
Email
(Required)
Attorney
Date
(Required)
MM slash DD slash YYYY
Symptoms
Untitled
(Required)
I allow Perfect White Smile to contact us through text message
CAPTCHA
This field is hidden when viewing the form
Site Name
This field is hidden when viewing the form
Site Phone
Contact Us
First Name
Last Name
Phone
(Required)
Email
(Required)
Workers Compensation Insurance carrier and adjustment information
Carrier Name
Adjuster Name
Phone
(Required)
Email
(Required)
Attorney
Date
(Required)
MM slash DD slash YYYY
Symptoms
Untitled
(Required)
I allow Perfect White Smile to contact us through text message
CAPTCHA
This field is hidden when viewing the form
Site Name
This field is hidden when viewing the form
Site Phone
