Health history, and Consent forms.

To arrange a Dental Mobile visit;

Please follow the instructions below.

The process is simple and efficient, as we are anxious to bring our program to you.

Step #1

Contact Director of Patient Relations at Dental Mobile, at (800) 700-7430 to schedule a visit.

Step #2

Download the Application Form and the Patient Medical History Form. Photocopy and

distribute both forms to all interested individuals.

Application and Consent Form ( English) (Spanish) (Korean)

Patient Medical History ( English) (Spanish) (Korean)

Step #3

Fax the completed Application forms to:

            Director of Patient Relations Dental Mobile at (800) 700-7430 or,

you can mail them to:

Dental Mobile

1659 Scott Blvd. Suite 2,

Santa Clara, CA 95050.

Note: The Patient Medical History forms will be available at the Mobile and can be completed by the patient before his or her appointment.