Silverbell office Pueblo Dental Center

"Catering to Cowards"

Valencia office
1000 N. Silverbell Rd
1400 W. Valencia Rd Suite 100
Tucson, AZ 85745
Hours: Monday - Friday 8 am to 5 pm Tucson, AZ 85746
(520) 624-7514
(520) 746-1068
FAX: (520) 624-7522
FAX: (520) 573-1887

 

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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
  2. Medical History
  3. Office Policy
  4. Privacy Policy Signature Sheet
  5. Privacy Policy Page 1
  6. Privacy Policy Page 2

Spanish

  1. Informacion Del Paciente
  2. Informacion Dental/Medica
  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 this form and mail or fax it to us.

Release of Records Form

 

If a patient under 18 comes in for an appointment, they must be accompanied by a legal guardian. If anyone other than the legal guardian is to bring them, this document must be signed stating that the patient can be brought by someone other than their guardian. This form must also be notarized.

Legal Guardian Release Form