About Us
Health Care Services
Dental Health Matters
Your School
Supporting Letters
In The Newsroom
 Forms :

Health history, and Consent forms.



To arrange a Health 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 Health Mobile, at (408) 879-0110 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 Health Mobile at (408) 244-9553 or,

you can mail them to:

Health Mobile

1659 Scott Blvd. Suite 4,

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.


All contents © copyright 2009 Health Mobile All rights reserved.