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
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
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: