Patient Registration Forms
The forms listed below are provided to allow those who wish to complete their new patient paperwork at home to do so. You may download and fill them out at your convenience before your first appointment. Bring the completed forms, a photo ID, and your insurance card(s) with you to your appointment. Our Customer Service Representative will enter your information into our Electronic Health Record System.
You will need Adobe Acrobat Reader to read and print these forms. You can download Adobe Acrobat Reader here.
Arabic Forms
- DAP Health Notice of Privacy Practices- Arabic
- Screening Checklist for Contraindications to Vaccines for Children and Teens - Arabic
- Screening Checklist for Contraindications to Vaccines for Adults - Arabic
** A copy of the immunization record will also be needed for all adults and children.
Please, bring all immunization records to every visit with us.
English Forms
Medical
- Behavioral Health Record Release Form
- DAP Health Consent Form
- DAP Health Notice of Privacy Practices
- Medical Record Release Form
- Patient Registration Form
- Tuberculosis Questionnaire
- Additional Family Members Form
- Adult Past Medical History (18+ Years)
- Pediatric Past Medical History - 0 - 2 Months
- Pediatric Past Medical History - 2 - 12 Years
- Pediatric Past Medical History - 12 - 17 Years
- Screening Checklist for Contraindications to Vaccines for Adults
- Screening Checklist for Contraindications to Vaccines for Children and Teens
Dental
- Adult Dental Health History Form
- Child Dental Health History Form
** A copy of the immunization record will also be needed for all adults and children.
Please, bring all immunization records to every visit with us.
Spanish Forms
Medical
- Autorización de Uso o Revelación de Información de Salud Personal
- Consentimiento General Para el Tratamiento Medico
- Aviso de Prácticas de Privacidad
- Autorización para Uso y Divulgación de Información Médica Protegida
- Formulario de Registro para Pacientes
- Cuestionario sobre Tuberculosis
- Formulario para Miembros Familiares Adicionales
- Historial del Pasado Medico para Adultos (18+ años)
- Historial del Pasado Medico para Niños de 0 a 2 meses
- Historial del Pasado Medico para Niños de 2 meses a 12 años
- Historial del Pasado Medico para Niños de 12 años a 17 años
Lista de Verificación para Contraindicación de Vacunas para Adultos
​Lista de Verificación para Contraindicación de Vacunas para Niños y Adolescentes
Dental
- Salud de Adultos / Historia Dental
- Historial Dental y Médica de su Pacient
** Una copia de la tarjeta de inmunización también será necesaria para todos los adultos y niños.
Por favor, traiga todos los documentos de inmunización para cada visita con nosotros.