Home > My First Visit > Forms

Forms

Release of Information Form (PDF) - Authorization to Use and Disclose Protected Health Information

Patient Information and Demographic Form (PDF)

Health History Form for Dental Appointments (PDF)

Health History Form for Medical Appointments (PDF)

Sliding Fee Scale Application (PDF)

  • What you need for your first visit

    For your first visit at The Lakes CHC please ensure you have brought the following items:

    • Photo I.D.
    • Insurance Information
    • List of medications, vitamins, supplements you are currently taking
    • For sliding fee scale applicants: application form and proof of income