Kathleen Gilmore, DMD
Jorge E. Vallejo, DMD

New Patient Forms

We are happy to offer our patient forms online. Please feel free to print and fill them out at your convenience before your visit.


New Patient Registration

Please download, print and complete this form before your first dental appointment.
Click here to download - ENGLISH (70 KB)
Click here to download - PORTUGUESE (70 KB)
Click here to download - SPANISH (70 KB)


Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information.
Click here to download (229 KB)


HIPAA Form

Please download, print and complete this form before your first dental appointment. This form confirms that you read our Notice of Privacy Practices.
Click here to download (295 KB)


 
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