Patient Forms
Forms to Download and Print
All forms must be returned to us by the patient/signer in person.
General Forms:
Permission to Share My Personal Health Information
Permission to Release Medical Records
Patient Complaint “Grievance” Form
Parental Consent Form for Elsie Allen
Visit Specific Forms
Tele-Dental Visit Instructions
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:
- No forms needed
9 Month Visit:
12 Month Visit:
15 Month Visit:
- Staying Healthy Assessments (SHA) 1-2 yrs.
- Ages and Stages (ASQ)
18 Month Visit:
2 Year Visit: