Patient Forms

Click here for New Patient Forms
- Once you fill out these forms, the Access to Care team will give you a call to arrange your initial visit. Please note that filling out this form does not automatically make you a patient of CHC.
- Patients at our Hartford site: Please note that if this form is not filled out, we will not be able to schedule your initial appointment.
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
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