Patient Forms

New Cleveland TX Dental Patient Forms 

For your convenience we have made a variety of our Patient Forms available online. Please print and complete these forms prior to your visit so that we may attend to your needs more quickly. If you have any questions please contact us at our Cleveland, TX dental practice today! If you are a new patient please fill these out and you information will be sent directly to our office:

ONLINE Patient Forms

Online Patient Forms **************These forms will directly import into the Office's computer) If you have any difficulty and are unable to do these or require a Spanish version, then you can print below the form that you need, fill it and bring to the office with you)

New Patients--Please fill out these 3 forms (New patient Form, HIPAA Communication Form, Consent for Treatment in Absence of Guardian Form).

Existing Patients--Please fill out these 3 forms (Medical History and Patient Screening Form, HIPAA Communication Form, Consent for Treatment in Absence of Guardian Form).

Patient Forms (only if unable to fill out the above Online Form)

New Patient English Form      
New Patient Spanish Form    

Existing Patients Medical History and Screening Form

English

Spanish

HIPAA Communication and Consent for Treatment in Absence of Parent/Legal Guardian Forms

HIPAA Communication Form

HIPAA Communication Form (Spanish)

Consent for Treatment in Absence of Guardian English

Consent for Treatment in Absence of Guardian Spanish

Medicaid Home Care

Home Care Questionnaire English    
Home Care Questionnaire Spanish