Patient Forms

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 Signature on File – Silverbell
3. Authorization for Signature on File – Valencia
4. Office Policy
5. Privacy Policy Signature Sheet
6. Privacy Policy Page 1
7. 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 complete and sign the form and mail or fax it to Pueblo Dental Center. Our address and fax number are listed here.

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