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 – English / 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 English – Page 2 English / Page 1 Spanish – Page 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
