Talkeetna: (907) 733-2273 ~ Willow: (907) 495-4100 ~ Wasilla: (907) 376-2273

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.

New Patients

Prior to your first appointment, you will receive text communication from a company named Phreesia. By clicking the link provided, you can complete most paperwork prior to your appointment on your smartphone. Additionally, you can confirm your upcoming appointment via text if you do not want a confirmation call from the clinic the afternoon before your appointment. If there are any questions regarding Phreesia or the paperwork you are asked to complete, please call Patient Services at Sunshine, and we will be able to assist you.

If completing forms via text link from a smartphone is not an option, you can print and complete this New Patient Forms Packet in advance and bring them to your appointment.

New Patient Forms Packet

Additional Forms

TitleDescriptionDownload
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.

DownloadPreview
CDL.DOT-MedicalExamReportForm-

Commercial driver medical examination report form.

DownloadPreview
CDL.DOTMedicalExamCertificate

Commercial driver's medical examiner's certificate form.

DownloadPreview
Consent to Discuss Information DownloadPreview
Declaration of no income DownloadPreview
Dental Health History - Adult

Dental health history form for ages 13 and older.

 

 

 

DownloadPreview
Dental Health History - Pediatric

Dental health history form for children 12 and under.

 

DownloadPreview
Grievance / Complaint 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.

DownloadPreview
Health History Adult

Health history form for adults.

DownloadPreview
Health History Pediatric Care

Health history form for children.

 

DownloadPreview
Notice of Privacy Practices Acknowledgement

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

DownloadPreview
Patient Financial Responsibility

Patient's acceptance of financial responsibility for services received.

DownloadPreview
Patient Information-Profile

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

DownloadPreview
Permission for Family Access to PHI DownloadPreview
Release of Behavioral Health Information DownloadPreview
Release of Information DownloadPreview
Slide Eligibility Application

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

DownloadPreview
Substance Use Form

Substance use assesment and history.

DownloadPreview