Patient Forms

At ReGenesis Health Care, we ask each patient to complete the appropriate forms and bring them with you to your next appointment. Please take the time to fill out all the necessary forms and present them upon arrival. Doing so will help us keep all of our appointments on time and will shorten the amount of time it takes for you to receive the care you need. Thank you and we look forward to seeing to you!

Pediatric Registration Packet Pediatric Registration Packet (2344 KB)

Adult Registration Packet Adult Registration Packet (1999 KB)

Patient Checklist Patient Checklist (133 KB)

NO SHOW POLICY NO SHOW POLICY (120 KB)

Adult Dental Patient Registration Packet Adult Dental Patient Registration Packet (845 KB)

Dental General Consent To Treat Form Dental General Consent To Treat Form (49 KB)

Pediatric and Adult Annual Update Form Pediatric and Adult Annual Update Form (433 KB)

Self-Declaration Self-Declaration (80 KB)

Pediatric Dental Registration Packet Pediatric Dental Registration Packet (135 KB)

Sliding Fee Sliding Fee (14 KB)

Spanish Forms

Paquete de Registracion de Adultos Paquete de Registracion de Adultos (515 KB)

Paquete de Registracion de Pediatrico Paquete de Registracion de Pediatrico (670 KB)

NO SHOW POLICY - SPANISH NO SHOW POLICY - SPANISH (103 KB)

Dental Consent To Treat Dental Consent To Treat (34 KB)

Patient Checklist Patient Checklist (41 KB)

Pediatric and Adult Annual Update Form Pediatric and Adult Annual Update Form (325 KB)

Sliding Fee Spanish Sliding Fee Spanish (15 KB)

Adult & Pediatric Registration Form Spanish Adult & Pediatric Registration Form Spanish (237 KB)

Self-Declaration Spanish Self-Declaration Spanish (34 KB)


Our MISSION

The Mission of ReGenesis Health Care is to provide culturally competent quality patient-centered health care that is affordable and accessible in partnership with the communities we serve.