Health Services Forms

These forms are available in our office, but have been put online for your convenience. To use these forms, you will need to have Adobe Acrobat installed. Please fill out these forms, print them and turn them in to our office in Curry Hall.

For your first appointment, please have these forms filled out and with you:
Patient Registration Form
Patient Consent Form
Income Affidavit
Client Health History
Acknowledgement Form
Immunization Form

If you need to request records from our facility or another facility, please complete the following form:
Authorization for Release of Records and Request for Records

Notice of Privacy Practices — Please read our privacy practices to answer any questions or concerns you may have. Once you have read the information, please complete the Acknowledgement Form above. Please contact us at 575.562.2321 for more information.