Wesley Health Centers Patient Information Forms

New patients can save time during their first appointment by completing the necessary forms prior to seeing your Wesley Health Centers doctor.
Simply print out the appropriate form, fill in the information requested, and bring the completed form with you to your appointment.

Patient Information Form

Patient Information Intake Form  – Fillable / English / Spanish

Medical Consent for Pediatrics – English

Medical Records Authorization – Fillable

Patient Forms for Dental Care

Dental Patient Intake Form – English / Spanish

Adult Dental History – English/Spanish

Adult Health Questionnaire – English / Spanish

Dental Treatment Consent Form – English / Spanish

Consent for Teledentistry Visit – English / Fillable English / Fillable Spanish

Dental Materials Fact Sheet – English / Spanish

Patient Acknowledgement Form for Dental Materials – English / Spanish

Pediatric Health History Questionnaire – English / Spanish

Broken Appointment Policy – English / Spanish

Patient Forms for Nutritional Services for People Living with HIV/AIDS (PLWHA)

Nutritional Services Enrollment Form – Fillable English / Fillable Spanish

Nutritional Services Eligibility – English

Nutritional Services Locations – English / Spanish

COVID-19 Patient Information Forms

Patient Information & Consent Form English / Spanish

Patient Pre-test Questionnaire English / Spanish

COVID-19 Patient Dental Forms

Dental Screening Form Page 1 EnglishPage 2 English / Page 1 SpanishPage 2 Spanish

Dental Protocols English / Spanish

Dental Treatment Consent Form English / Spanish

Staying Healthy Assessment Forms

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

Adult English / Spanish

Senior English / Spanish

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