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.

  • New Patient Form: Click Here
    • Fill out this form completely and hit “submit,” and someone from our team will reach out over the phone to schedule your initial visit.
    • Please note that submitting this form does not automatically make you a patient of CHC.
  • Access Your Health Information
    • If you would like to request access to your health information, or allow another person or organization to access your health information, look at the options below, or visit any CHC site to fill out the forms in person.
    • You can access your medical records, appointment history, test results, and more on the Patient Portal, myCHC.
    • If you need CHC to send your health information to another practice, company, or person, click here.
    • If you need another practice to send your health records to CHC, click here.
  • Consent for Care of a Minor
    • If you are with a minor (patient under 18) who is receiving care from us, please fill out this form.
  • Permission to Share Health Information
    • If you would like us to be able to share your health information with certain people you choose (such as close relatives) fill out the form above.
  • Click here for Sliding Scale Fee Application
  • School-Based Health Center Enrollment
  • Mobile Dental Enrollment Forms
Questions? Contact us at (860) 347-6971
110701 865 Crop
Our team is here to help!