Patient Checklists

Click below to open form or checklist

Form Name	Link
Limited Exam Checklist	PDF document
Hygiene Patient Checklist	PDF document
Doctor Patient Checklist	PDF document

 

General Patient Forms

Click below to open form or checklist

Form Name	Link
Excuse Form	PDF document
Exit Letter	Word document
Fast Checkout Form	PDF document
Guarantee / Patient Concern Form	PDF document
Guardian Medical Decision Transfer Authorization	PDF document
Insurance phone form	PDF document
Internship & Community Outreach Program	PDF document
Medicaid Pre-Authorization Form	Blank	Sample
Medicare Discount Plan	PDF document
Membership Discount Plan	English	Spanish
Membership Plan Renewal Letter	Word document
Morning Team Huddle	PDF document
New Patient & Health History Form	English	Spanish
New Patient Sports Guard	PDF document
Referral Form	PDF document
Substance Abuse Resources	PDF document	LDS Addiction Site
Waiting & Play Room Hourly Cleaning Checklist	PDF document
Weekly Cleaning Checklist	PDF document
Wisdom Teeth Packet	PDF document