Silverbell office Pueblo Dental Center Valencia office
1000 N Silverbell Rd
1400 W Valencia Rd Suite 100
Tucson, AZ 85745
  Tucson, AZ 85746
(520) 624-7514
"Catering to Cowards" (520) 746-1068
FAX: (520) 624-7522
FAX: (520) 829-7687
Monday-Friday 8:00am-5:00pm   Monday-Friday 8:30am-5:00pm

 

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New Patient Forms

Please fill out and sign pages 1-4, and bring them with you to your first appointment.

English

  1. New Patient Information & Medical History
  2. Authorization for Signatue on File
  3. Office Policy
  4. Privacy Policy Signature Sheet
  5. Privacy Policy Page 1
  6. Privacy Policy Page 2

Spanish

  1. Informacion Del Paciente & Informacion Dental/Medica
  2. Authorizacion de Firma el Archivo
  3. Reglamento De La Oficina
  4. Hoja Para Firmar Sobre Los Reglamentos De Privacidad
  5. Reglamentos De Privacidad 1
  6. Reglamentos De Privacidad 2

 

 

Release Forms

If you would like a copy of your x-rays or records, we require that you sign a Release of Records Form. Please fill out and sign this form. You may mail it to us or fax it to us. Our address and fax number is listed above.

Release of Records Form

Authorizacion Standard del Uso y Revelacion de Informacion de Salud Confidencial

 

Patients under the age of 18 must be accompanied by a legal guardian to their appointments. If anyone other than a legal guardian is to bring them, they must have a Legal Guardian Release Form filled out, signed and notarized. Please note: This form must be notarized.

Legal Guardian Release Form