Save time at your first visit to Wesley Health Centers. Just print, fill out, and bring your forms with you.
If you don’t have access to a printer, we’ll be happy to provide the forms for you at our clinics.
Dental & Oral Health Care
Patient Intake Forms
1. Intake Forms – English | Spanish
2. Adult Health History – English | Spanish
3. Dental Health History – English | Spanish
4. Pediatrics Health History – English
5. Dental Treatment Consent – English | Spanish
6. Dental Materials Fact Sheet – English | Spanish
7. Patient Acknowledgement of Dental Materials – English | Spanish
8. Broken Appointment Policy – English | Spanish
9. Consent for Teledentistry Appointment – English | Fillable English
Food Pantry & Nutritional Services
Patient Intake Forms
Nutritional Services Enrollment Form – English / Spanish
Nutritional Services Eligibility – English
Nutritional Services Locations – English / Spanish
Staying Healthy Assessment
Forms for Adults
Staying Healthy Assessment
Forms for Pediatrics
Age 0-6 months – English / Spanish
Age 7-12 months – English / Spanish
Age 1-2 years – English / Spanish
Age 3-4 years – English / Spanish
Age 5-8 years – English / Spanish
Age 9-11 years – English / Spanish
Age 12-17 years – English / Spanish
Staying Healthy Assessment
Forms for Seniors
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No one is turned away due to lack of ability to pay for services or due to being uninsured.
We also offer a sliding fee schedule for persons at or below 200% of Federal Poverty Income Guidelines.
The Health Resources and Services Administration (HRSA) consider JWCH Institute, Inc. / Wesley Health Centers and its providers as Public Health Services employees, providing malpractice liability protection under the Federal Tort Claims Act (FTCA). This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
