The following forms have been provided for your convenience and may be referred to for additional information regarding our services and procedures.

Patient Forms

• Patient Registration Form (PDF document)
• Authorization for Release of Information (PDF document)
• Office Policies for New Patients (PDF document)
• Patient Medical Questionnaire (PDF document)
• Permission to Discuss Patient History Information Form (PDF document)

Sliding Scale Forms

• 2011 Sliding Fee Application and Income Guidelines (PDF document)
• Food Stamp Verification Form
• Statement of Self-Employment (Including odd jobs)
• Self Declaration of Income (for zero income)
• Employer Statement of Income

Financial Forms

Pediatrics and Well Child

• 0-6 Years Immunization Schedule (PDF document)
• 7-18 Years Immunization Schedule (PDF document)