patient-care-forms | College of Dentistry and Dental Clinics

Patient Forms

New patients to the College are expected to complete the following forms. For your convenience the following forms can be completed and printed off in advance of your appointment. Please bring these forms with you to your appointment.

Becoming a Patient in the Student Clinics (.pdf)
Patient Registration Form (.pdf)
Registro del Paciente (.pdf)
Health History Form (.pdf)
Cuestionario de Salud (.pdf)
Pediatric Health History Form (.pdf)
Historia de salud pediátrica (.pdf)
Medications Form (.pdf) **Please bring with health history
Medicamentos (.pdf) **Please bring with health history
Patient Treatment Consent/Agreement Form (.pdf)
Formulario de consentimiento / acuerdo para el tratamiento del paciente (.pdf)
Student Clinic Care Agreement Form (.pdf)
Authorization for Release of Protected Health Information to a Designated Adult (.pdf)
Autorización para divulgar información médica protegida a un adulto designado (.pdf)
Patient Survey
Consent to Communicate PHI by Email Form (.pdf)
Consent to Communicate PHI by Email Form - Spanish (.pdf)

Requesting Dental Records

If you need copies of your dental records and/or radiographs, please print, complete and sign both the Consent to Release Health Information and the Consent to Communicate PHI by Email forms below and return them to the College of Dentistry. Both of these forms are required prior to the release of your dental records. If you have any questions please contact Central Records at 319-335-7429.