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PATIENT FORMS

Please click the links below to fill out the required forms and submit them back to us.

Patient Paperwork
(all 5 forms need to be filled out for new patients)
(click on the link, fill out the form, save it to your computer and e-mail to frontdesk@caringhandsdc.org for the Alexandria location and pipestone@caringhandsdc.org for the Pipestone location.)

Patient Information

English

Medical History

Appointment Policy

Notice of Privacy Practices

Espanol

Informacion del Paciente

Historial Medico

Historia Dental

Politica de Citas

Aviso de Practicas de Privacidad

Release of Information
(click on the link, fill out the form, save it to your computer and e-mail to frontdesk@caringhandsdc.org for Alexandria location and pipestone@caringhandsdc.org for Pipestone location)

Release of Information-INTO Caring Hands

English

Release of Information-OUT of Caring Hands

Espanol

Divulgacion de informacion-INTO Caring Hands

Divulgacion de informacion-OUT of Caring Hands

Sliding Fee Scale
(click on the link, fill out the form, save it to your computer and e-mail to frontdesk@caringhandsdc.org for Alexandria location and pipestone@caringhandsdc.org for Pipestone location)

Sliding Fee Scale Instructions and Application

English

Espanol

Instrucciones y solicitud de la escala movil de tarifas

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