At Smile Generation, we recognize that our relationship with you is based on integrity and trust, so we first need to verify your identity. Please complete this form so that we may begin that process. It is critical that all of your information is entered accurately to ensure optimal results.


If you have Power of Attorney, Legal Guardianship, or other adjudication of authority to act in this capacity for another person and are submitting a request on behalf of that person, please send a letter containing the request type(s) e.g. (Request to Know, Delete) together with a copy of your adjudication of authority to:


Compliance & Ethics Department,

Pacific Dental Services,

17000 Red Hill Ave, Irvine,

CA 92614.

Are you an existing patient, or have you received promotions from us?
Existing Patient
Not a Patient
Current Employee
Previous Employee
Job Applicant
Request to Know
Request to Delete
Request to Correct
Enter the first name of the data subject
Enter the last name of the data subject
Yes
No
Yes
No
I agree, and confirm

By submitting this request, I consent to receive phone calls from Pacific Dental Services or Smile Generation, at the phone number above, including my wireless number if provided, for purposes of processing my CCPA request.