Please find the applicable form below. You can either “Download” or “Preview” by clicking the respective link/button.
To complete a form:
- Click “Download” and save the document to your local hard drive computer/device.
- Open the document from the location you saved it in using a free .pdf reader like Adobe Acrobat Reader.
- A light purple field indicates that it is fillable. Click each field and enter your information.
- Print the file.
- Bring the forms to the health center for your next appointment.
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
|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.
Commercial driver medical examination report form.
Commercial driver's medical examiner's certificate form.
|Consent to Discuss Information||DownloadPreview|
|Declaration of no income||DownloadPreview|
|Dental Health History - Adult|| |
Dental health history form for ages 13 and older.
|Dental Health History - Pediatric|| |
Dental health history form for children 12 and under.
|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.
|Health History Adult|| |
Health history form for adults.
|Health History Pediatric Care|| |
Health history form for children.
|Notice of Privacy Practices Acknowledgement|| |
Acknowledgment and consent of SCHC's Notice of Privacy Practices.
|Patient Financial Responsibility|| |
Patient's acceptance of financial responsibility for services received.
|Patient Information-Profile|| |
New patient registration. Also applies to patients that have not received care at at SCHC for over 1 year.
|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.
|Substance Use Form|| |
Substance use assesment and history.