Forms

All important patient forms and files can be viewed and downloaded below. 

How to Use Fillable Forms

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Screening Schedule for 2024

• Screening Schedule

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Patient Forms

Dental

• Informed Consent
• Medical History
• Community Resource Guide
• Permission to Accompany-Treat Minor

Medical

• New Medical Patient Application
• Patient Rights and Responsibilities
• Community Resource Guide
• Permission to Accompany-Treat Minor

Belmont Career Center - School Based Health Center

• SBHC Enrollment Form
• SBHC Consent Form
• Community Resource Guide
• Permission to Accompany-Treat Minor

Privacy Practices

• Notice of Privacy Practices for Health Information Exchange (HIE)
• Notice of Privacy Practices

Patient Discount Program

• Patient Discount Application
• Patient Discount Income Chart

Community Health Needs Assessment

• 2021 Community Health Needs Assessment