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Patient Intake Forms


 

To ensure that you begin your appointment on time, please fill out the new patient forms below. Simply print and fill out the forms at home then bring them to our office upon arriving for your first appointment. 

 

Patient Intake Forms - Full Packet

Click HERE to access the Full Patient Packet

Individual Forms Below

01.1 Welcome Form

02.1 Patient Registration Form

03.1 Dental Questionnaire

03.2 Medical Questionnaire 

04.1 Financial And Payment

05.1 Assignment of Benefits

06.1 HIPAA Notice of Privacy Practices

06.2 HIPAA Authorization Acknowledgement and Consent

Tereza Hambarchian, DDS

Dentist located in Glendale, CA

Dr. Tereza Hambarchian's dental practice, ProDent Care, located in Glendale, California, provides important dental health services to patients throughout the Los Angeles, CA area. Dr. Hambarchian offers services such as fillings, crowns, bridges, veneers, extractions, dental implant restoration, teeth cleaning & whitening, Invisalign®, sleep apnea treatment, and root canal therapy.

Dr. Hambarchian is a graduate of University of Southern California School of Dentistry. She is a member of the American Dental Association, the San Fernando Valley Dental Society, and the California Dental Association. She is also a regular volunteer in the community by promoting the importance of dental health to the residents of Glendale, CA. 

Dr. Hambarchian has completed extensive continuing education courses in different areas of dentistry since 2005. She is dedicated to continually improving her clinical skills and artistry to best serve her patients. Dr. Tereza Hambarchian is gentle, kind, patient, and compassionate. She is dedicated to excellence and takes great pride in offering the finest in patient care and services in Glendale, California. Both adults and children are welcomed as new patients at her practice. She also offers care in English, Spanish, Farsi, and Armenian.

The office holds high standards of health, striving to make your visit comfortable, secure, and memorable. ProDent Care is a patient-centered dental practice with the mission of excellence in promoting, providing, and preserving dental health for each and every patient. 

Dr. Hambarchian and the entire staff at ProDent Care welcome all new patients to the practice for general and cosmetic dentistry, where most major forms of dental insurance are accepted, including CareCredit


What we offer

Services We Provide

ProDent Care

  • Our Mission

    ProDent Care is a patient-centered dental practice with a mission of excellence in promoting, providing and preserving dental health.

    Core Values

    Trust: “We can count on each other.”

    Excellence: “We do our best at all times and look for ways to do it even better.”

    Accountability: “We accept responsibility for our actions.”

    Mutual Respect: “We treat others the way we want to be treated.”

    Transparency: “We support providing patients with information about the quality and cost of their health care options.”

Click Here To Learn More About ProDent Care

Click Here To Learn More About ProDent Care

We are a Proud Member of

Insurance

We accept most insurance plans and will gladly process your claim. Please bring the necessary information with you on your first visit. Insurance policies generally cover only a portion of the total treatment cost. Unless other arrangements have been made, we ask that you pay your portion of the bill at the time of treatment. It is your responsibility to pay any balance not paid by your insurance company. We accept Visa, Mastercard, American Express, Discover. For your convenience, we also accept PayPal and CareCredit.

Aetna
Anthem
Blue Cross Blue Shield
CareCredit
Cigna
Connection Dental
Delta Dental
Dental Benefit Providers
Dental Health Alliance
GEHA
Guardian
Humana
MetLife Dental
Premier Access
Principal Financial Group
Tricare
Testimonials

Words from our patients

  • Yelp

    "She makes sure you are comfortable while working on your teeth, and that you walk out with a brighter smile at the end of your appointment."

    T K.
  • Yelp

    "Dr. Tereza doesn't treat you for anything you don't need done - she gives you an honest assessment."

    Lee K.
  • Yelp

    "The best part of the whole experience is Dr. Tereza's warmth and honesty. She explained each thing she was going to do, went over my digital X-rays with me."

    Rinz Z.
  • Yelp

    "Dr. Tereza is not only an amazing dentist, she's also one of the kindest, warmest people I've ever met. She's highly detailed and truly cares. That is so rare."

    Laura H.
  • Yelp

    "The best part of the whole experience is Dr. Tereza's warmth and honesty. She explained each thing she was going to do, went over my digital X-rays with me."

    Rinz Z.
  • Yelp

    "Dr. Tereza is not only an amazing dentist, she's also one of the kindest, warmest people I've ever met. She's highly detailed and truly cares. That is so rare.

    Laura H.
  • Yelp

    "I never feel like she's in a rush to move on to the next patient - she takes her time to make you feel relaxed and comfortable, and takes the time to do a thorough job."

    Lee K.
  • Yelp

    "Aside from her great skill, the office is modern and clean, and parking is never an issue. You wont regret making an appointment with her- and neither will your teeth!"

    T K.
  • Yelp

    "I had a deep cleaning and it was amazing. No pain and great results. Glad to find a dentist like her. I will recomend her to anyone."

    Karla A.
  • Yelp

    "She is very knowledgeable and an amazing diagnostician and the nicest person. Try her. You will thank me."

    Deb K.
  • Yelp

    "Dr. Tereza was very sensitive to my dental needs and walked me through each of my x-rays to show me filings, bone density, and root structures of my teeth."

    Hannah F.
  • Yelp

    "I highly recommend her. She is friendly, personable and very good at her craft. Her staff, professional and personable"

    JL L.
  • Yelp

    "I'm thrilled they did this- upon accepting my insurance they made sure to give me a very clear run down of what my insurance covers."

    David C.
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Feel free to email us regarding any scheduling or general questions!

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Tereza Hambarchian, DDS
213 North Orange Street
Suite F
Glendale, CA 91203