Patient Forms & Educational Material
To make your first visit easier, below are forms that you will be asked to complete prior to your first visit. If possible, please complete all of the information below and bring it along with you.
If you need assistance completing any of these forms, call the dental center.
Baker Victory Dental Center
- Patient Registration (Also available in Arabic & Spanish)
- Medical History (Also available in Arabic & Spanish)
- Consent To Use and Disclose Protected Health Information For Treatment, Payment and Health Care Operations (Also available in Arabic & Spanish)
- Consent for Dental Treatment and Anesthesia (Also available in Arabic & Spanish)
- Patient Bill of Rights
School-Based Dental Program
- CHOMPERS Enrollment Form (Also available in Arabic and Spanish)
- CHOMPERS 2016-2017 Calendar
- CHOMPERS Parent Survey
- CHOMPERS Staff Survey
To download a free copy of Adobe Acrobat, visit get.adobe.com/reader/