Rolling Hills Clinic serves the medical and dental needs of all - from infants and teens to adults and seniors.

Patient Forms and Documents

The Rolling Hills Clinic patient forms and documents section contain important forms you may choose to complete and bring to your first visit. Filling out these forms prior to your visit will save you time when you arrive to the clinic.

Visits are by appointment only. Please call in advance to schedule your appointment. 

New Patient Packets

New Patient Packet (ENGLISH) (6353 KB)

New Patient Packet (SPANISH) (5203 KB)

New Patient Forms in English

Registration (499 KB)

Health History (319 KB)

No Show Policy (308 KB)

Financial Agreement & Notice of Privacy Policy (278 KB)

Dental Materials Fact Sheet (460 KB)

New Medical Patient Request Form

New Patient Request Form (317 KB)

New Dental Patient Request Form

New Dental Patient Request Form (406 KB)

Medicare as a Payer Questionnaire

Medicare as a Payer Questionnaire (402 KB)

Medicare as a Secondary Payer Questionnaire (SPANISH) (425 KB)

New Patient Forms in Spanish

Registration (SPANISH) (117 KB)

Health History (SPANISH) (318 KB)

No Show Policy (SPANISH) (108 KB)

Financial Agreement & Notice of Privacy Policy (SPANISH) (87 KB)

New Patient Request (SPANISH) (278 KB)

Patient Complaint Form

Patient Comment/Concern Form (321 KB)

 




 

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