Forms

Patient Registration Form

Patient Bill of Rights and Responsibilities

Notice of Privacy Practices – Updated June, 2021

Dental Patient Medical History Form

School-Based Dental Center Medical/Dental History

Dr. Dynasaur Coverage Info

Sliding-Fee Scale Application

Consent to Disclose Health Information

CHCB Application for Employment

Advance Directive Information and Form

Child Psychiatry Consultation Clinic Referral Form

 

Translated Materials

Patient Registration Form – Arabic

Patient Registration Form – Burmese

Patient Registration Form – Dari

Patient Registration Form – Farsi

Patient Registration Form – Nepali

Patient Registration Form – Pashto

Patient Registration Form – Somali

Patient Registration Form – Spanish

Patient Registration Form – Vietnamese

 

Dental Patient Medical History – Arabic

Dental Patient Medical History – Burmese

Dental Patient Medical History – Dari

Dental Patient Medical History – Nepali

Dental Patient Medical History – Pashto

Dental Patient Medical History – Somali

Dental Patient Medical History – Vietnamese

 

Sliding-Fee Scale Application – Arabic

Sliding-Fee Scale Application – Burmese

Sliding-Fee Scale Application – French

Sliding-Fee Scale Application – Nepali

Sliding-Fee Scale Application – Somali

Sliding-Fee Scale Application – Spanish

Sliding-Fee Scale Application – Vietnamese

 

School-Based Dental History Pre-K through 12th Grade – Nepali

School-Based Dental History Pre-K through 12th Grade – Somali

 

Patient Rights and Responsibilities brochure – Arabic

Patient Rights and Responsibilities brochure – Burmese

Patient Rights and Responsibilities brochure – Nepali

Patient Rights and Responsibilities brochure – Somali

Patient Rights and Responsibilities brochure – Vietnamese

 

Notice of Privacy Practices brochure – Arabic

Notice of Privacy Practices brochure – Dari

Notice of Privacy Practices brochure – Farsi

Notice of Privacy Practices brochure – French

Notice of Privacy Practices brochure – Nepali

Notice of Privacy Practices brochure – Pashto

Notice of Privacy Practices brochure – Somali

Notice of Privacy Practices brochure – Swahili

 

Dr. Dynasaur Health Coverage info-Arabic

Dr. Dynasaur Health Coverage info-Burmese

Dr. Dynasaur Health Coverage info-Mandarin

Dr. Dynasaur Health Coverage info-Nepali

Dr. Dynasaur Health Coverage info-Somali

Dr. Dynasaur Health Coverage info-Vietnamese