Forms are available in Somali, English, Spanish, Russia, Hmong, Amharic and Vietnamese. For more information, please call 612-625-2495.
English Language Forms
- Registration Form
- Adult Health History Form
- Child Health History Form
- Release of Records
- Driving Directions
- Patient Bill of Rights
- CBCT Referral Form
- COVID-19 Clinical Intake (done at Moos Tower)
Spanish Language Forms (Formularios en Español)
- Registration Form (Formulario de registro del paciente)
- Adult Health History Form (Cuestionario médico y dental)
- Child Health History Form (Formulario de historia médica pediátrica)
- Release of Records Form (Revelación de expedientes)
- Driving Directions Form (Direcciones al edificio de estacionamiento)
- Patient Bill of Rights (Derechos y responsabilidades del paciente)
- COVID-19 Clinical Intake Form (Formulario de triaje de COVID-19)
Russian Language Forms (Русскоязычные формы)
- Registration Form (СТОМАТОЛОГИЧЕСКАЯ КЛИНИКА)
- Adult Health History Form (Вопросы о медицинских и стоматологических проблемах)
- Child Health History Form ИСТОРИЯ БОЛЕЗНИ (ПЕДИАТРИЯ)
- Release of Records Form (ВЫДАЧА ЗАПИСЕЙ)
- Driving Directions Form (ПАРКОВОЧНАЯ ПЛОЩАДКА НА WASHINGTON AVENUE)
- Patient Bill of Rights (Права и обязанности пациента)
- COVID-19 Clinical Intake Form (ФОРМА ОПРОСА В СВЯЗИ С COVID‐19)
Hmong Language Forms (Cov ntawv Hmoob)
- Registration Form (DAIM NTAWV SAU NPE NEEG MOB)
- Adult Health History Form (Lus Nug Txog Kev Kho Hniav thiab Kev Kho Mob)
- Child Health History Form (DAIM FOOS SAU KEEB KWM ME NYUAM YAUS KEV NOJ QAB HAUS HUV)
- Release of Records Form (NTHUAV TAWM NTAUB NTAWV SAU TSEG)
- Driving Directions Form (THOV COJ RAWS LI COV LUS QHIA NO MUS RAU)
- Patient Bill of Rights (Neeg Mob Cov Kev Muaj Cai thiab Cov Luag Hauj Lwm)
- COVID-19 Clinical Intake Form (DAIM FOOS COVID‐19 PEB CEG)
Amharic Language Forms (የአማርኛ ቋንቋ ቅጾች)
- Registration Form (የታካሚ ምዝገባ ቅጽ – የጥርስ ክሊኒኮች)
- Adult Health History Form (የሜዲካል እና የጥርስ ሕክምና መጠይቅ)
- Child Health History Form (የሕፃናት ጤና አጠባበቅ ታሪክ ቅፅ)
- Release of Records Form (የመረጃዎች መለቀቅ)
- Driving Directions Form (እባክዎ እነዚህን መመሪያዎች ለጥርስ ህክምና ትምህርት ቤት የመኪና ማቆሚያ ራምፕ ይከተሉ)
- Patient Bill of Rights (የታካሚ መብቶች እና ግዴታዎች)
- COVID-19 Clinical Intake Form (የCOVID‐19 የሙከራ ቅፅ)
Vietnamese Language Forms (Hình thức ngôn ngữ tiếng việt)
- Registration Form (BIỂU MẪU ĐĂNG KÝ BỆNH NHÂN)
- Adult Health History Form (Bảng Câu Hỏi Về Y Tế và Nha Khoa)
- Child Health History Form (BIỂU MẪU BỆNH SỬ NHI KHOA)
- Release of Records Form (TIẾT LỘ HỒ SƠ)
- Driving Directions Form (VUI LÒNG TUÂN THEO CÁC HƯỚNG DẪN NÀY DÀNH CHO BÃI ĐỖ XE DENTAL SCHOOL)
- Patient Bill of Rights (Quyền và Trách Nhiệm Của Bệnh Nhân)
- COVID-19 Clinical Intake Form (BIỂU MẪU SÀNG LỌC COVID‐19)
Somali Language Forms (foomamka af-soomaaliga)
- Registration Form (XARUMAHA CAAFIMAADKA ILKAHA)
- Adult Health History Form (Foomka Su'aalaha Caafimaadka Ilkaha)
- Child Health History Form (FOOMKA TAARIIKHDA CAAFIMAADKA CARRUURTA)
- Release of Records Form (SHAACINTA DIIWAANNADA)
- Driving Directions Form (FADLAN RAAC TILMAAMAHAAN SI AAD U GASHO AAGA BAAKINKA EE KULIYADA CAAFIMAADKA ILKAHA)
- Patient Bill of Rights (Xaquuqaha iyo Waajibaadka saaran Bukaanka)
- COVID-19 Clinical Intake Form (FOOMKA SADDEX GEESOODKA EE COVID‐19)