Our Patient Support Center can help you identify which form you need or speak to one of our front office staff. Just call 1.877.809.5092 and ask for help.
Patient Registration
Patient Acknowledgement
Authorization to Release Information by Phone or in Person
Release of Medical Records
Health History 0yrs-17yrs
Health History 18yrs and older
Dental Health History (for dental patients )
Acceptance of Financial Responsibility
Missed Appointment Agreement
Registro de Paciente
Reconocimiento del Paciente
Autorización para Divulgar Información de Salud Protegida por Teléfono o en Persona
Divulgación de Registros Médicos
Historia de Salud para Infantes y Menores de 17 años
Historia de Salud para Pacientes Edades 18 años y mayor
Historia de Salud para Pacientes Dentales
Aceptación de Responsabilidad Financiera
Aceptación de Responsabilidad Financiera
Acuerdo De Cita Perdida
Dental Patient Registration Form (English)
Dental Patient Registration Form (Spanish)
Dental Patient History Form (English)
Note: All Forms require the free version of Adobe Reader for viewing and printing. Download a free copy of Adobe Reader here.
This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
