Patient Forms

Forms to Download and Print

All forms must be returned to us by the patient/signer in person.

General Forms:

Sliding Scale Application

New Patient Registration Form

New Patient Registration Form (Spanish)

Permission to Share My Personal Health Information

Permission to Release Medical Records

Patient Complaint “Grievance” Form

Parental Consent Form for Elsie Allen

Advance Care Planning Packet

Rights Responsibilities Grievance

Rights Responsibilities Grievance (Spanish)

HIPAA Notice of Privacy Practices rev 2022 Spanish- SRCH 03-17-2022

 

Visit Specific Forms

Tele-Dental Visit Instructions

Well-Child Baby Visit

 

Tele-Dental Visit Instructions:

Visit Instruction Sheet in English

Hoja de instrucciones en español

 

Well-Child Baby Visits:

2 Month Visit:

4 Month Visit:

6 Month Visit:

9 Month Visit:

12 Month Visit:

15 Month Visit:

18 Month Visit:

2 Year Visit:

 

More Californians can get full Medi-Cal, regardless of immigration status! We can help you sign up. | ¡Más californianos pueden obtener Medi-Cal completo sin importar tu estatus migratorio! Nosotros podemos ayudarte a registrarte.Learn how | Aprende como aquí
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