Forms

Patient Forms for Public Health

DENTAL

Consent for Services

Permission to Delegate Dental Treatment and Disclosure of Health Information

Policies and Procedures

Patient Medical History

NEEDED FOR ALL CLINICAL SERVICES

Demographics Form (English/Spanish)

BREAST AND CERVICAL CANCER

Demographics Form (English/Spanish)

List of Acceptable Documents for Proof of Identification

List of Acceptable Documents for Proof of Income

FAMILY PLANNING

List of Acceptable Documents for Proof of Identification

List of Acceptable Documents for Proof of Income

Demographics Form (English/Spanish)

Female Reproductive Health History

IMMUNIZATION

Demographics Form (English/Spanish)

List of Acceptable Documents for Proof of Income

WIC

WIC PreScreening Tool

List of Acceptable Documents for Proof of Identification 

List of Acceptable Documents for Proof of Income

List of Acceptable Documents for Proof of Residence