Patient Forms

Please find the applicable form below. You can either “Download” or “Preview” by clicking the respective link/button.

To complete a form:

  1. Click “Download” and save the document to your local hard drive computer/device.
  2. Open the document from the location you saved it in using a free .pdf reader like Adobe Acrobat Reader.
  3. A light purple field indicates that it is fillable. Click each field and enter your information.
  4. Print the file.
  5. Bring the forms to the health center for your next appointment.

Title Description Download
Authorization for Care of Minor

Authorization for SCHC to provide care for your minor child. Also, authorizes other named adults to seek treatment for your child if indicated.

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Authorization to Release Information to Anyone

Authorization to allow friends or family members to call and request results of tests, procedures and financial information about you.

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Commercial driver medical examination report form.

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Commercial driver's medical examiner's certificate form.

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Dental Health History

Dental health history form for all aged patients.

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Health History Adolescent (13-18yr)

Health history form for children between the ages of 13 and 18 years old.

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Health History Adult

Health history form for adults.

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Health History Pediatric (up to age 12)

Health history form for children under age 12.

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Notice of Privacy Practices

Description of how medical information about you may be used and disclosed and how you can access this information.

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Notice of Privacy Practices Acknowledgement

Acknowledgment and consent of SCHC's Notice of Privacy Practices.

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Patient Financial Responsibility

Patient's acceptance of financial responsibility for services received.

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Patient Grievance Form

A formal expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family’s satisfaction at the point of service.

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Patient Information-Registration

New patient registration. Also applies to patients that have not received care at at SCHC for over 1 year.

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Release of Information

Authorization for SCHC to receive your information from another medical provider or to send your information to another medical provider.

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Slide Eligibility Application

Application for discount fee, based on income. Must be submitted to SCHC 48 hours BEFORE appointment.

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