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

Rights Responsibilities Grievance ENGLISH 09.19

HIPAA Notice of Privacy Practices rev 2022 – English – SRCH 3.17.22

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:

• Staying Healthy Assessments (SHA) 0-6 months

4 Month Visit:

• ACES/PEARLS

6 Month Visit:

• No forms needed

9 Month Visit:

• ACES/PEARLS
• Staying Healthy Assessments (SHA) 7-12 months

12 Month Visit:

• ACES/PEARLS
• Staying Healthy Assessments (SHA) 1-2 yrs.
• Ages and Stages (ASQ)

15 Month Visit:

• Staying Healthy Assessments (SHA) 1-2 yrs.
• Ages and Stages (ASQ)

18 Month Visit:

• Staying Healthy Assessments (SHA) 1-2 yrs.
• Ages and Stages (ASQ)
• MCHAT

2 Year Visit:

• ACES/PEARLS
• Staying Healthy Assessments (SHA) 1-2 yrs.
• Ages and Stages (ASQ)
• MCHAT