Important Forms

Important Forms

Download Registration Forms Here!

New Patients

Patient Information Form

Patient Consent Form

Financial Policy

Read our Privacy Practices Policy

Release of Medical Records

Release of Patient Medical/Dental Information Form

Patient Health Questionnaires

Adult Medical History for patients 18 and older

Depression Screening PHQ-9 for patients 13 and older

Pediatric Medical History for patients 17 and younger

Dental Medical History for all dental patients

Sliding Fee Discount Program

If you are applying for our Sliding Fee Discount Program, you will need to complete the following:

Sliding Fee Discount Application

List all family members and dependents living in your household.
A Family is one or more persons living in one dwelling place who are related by blood, marriage, or law.
A Dependent is someone who lives in your household and qualifies as a dependent for federal tax purposes.

Proof of Income (POI)

You will also need proof of income for all working family members for the past 30 days. We accept check stubs, SSI or Disability award letters, Child Support or Alimony orders, or Unemployment compensation. If you do not have any of these, the following alternative options may apply:

If you do not receive check stubs or have recently started a new job, please have your employer complete this form. It must be dated within fourteen (14) days of your scheduled appointment.

This is a signed form indicating your net income for the past month. You will also need to provide all of the following:

  • Pages 1 and 2 from Current Year Tax Returns
  • Schedule C, E, or F from Current Year Tax Returns
  • Bank statement from the past 30 days

Alternative Income Form

This is a signed form indicating that someone is supporting you at this time. To be eligible to use this form you must be:

  • Eighteen (18) or older
  • Unemployed
  • Supported by another individual (cannot be a spouse)