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

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


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: