Patient Forms

Welcome to CHC! Below are many of the forms that you will encounter during your time as a patient with us. These forms allow us to treat you, receive or send your medical records, help you pay for care, and more. If you are interested in becoming a new patient, please fill out the first form in the list.

• Release of Information
  • Please fill this form out completely and hand sign on the signature line. Then, you can either fax the completed form, mail it in, or bring it in to your site.
  • English
  • Spanish
  • Portuguese
  • Polish
• Consent for Care of a Minor
  • Please print this form and bring in to the minor’s next appointment.
  • English
  • Spanish
  • Portuguese
  • Polish
• Permission to Share Health Information
  • Please print, fill out, and bring to your next appointment.
• Click here for Sliding Scale Fee Application
• School-Based Health Center Enrollment
• Mobile Dental Enrollment Forms
  • English
  • Spanish
  • Polish