Patient Forms
View, download or print forms and resources for your appointment.
New patient forms
To save time, print and complete these forms. Bring them with you to your first appointment.
All patients--Patient Registration
- Patient Registration Form (English)
- Patient Registration Form (Amharic)
- Patient Registration Form (Khmer)
- Patient Registration Form (Somali)
- Patient Registration Form (Spanish)
- Patient Registration From (Tigrinya)
- Patient Registration Form (Traditional Chinese)
- Patient Registration Form (Vietnamese)
All Patients--Consent for Care and Treatment
- Patient Consent for Care and Treatment (English)
- Patient Consent for Care and Treatment (Amharic)
- Patient Consent for Care and Treatment (Khmer)
- Patient Consent for Care and Treatment (Somali)
- Patient Consent for Care and Treatment (Spanish)
- Patient Consent for Care and Treatment (Tigrinya)
- Patient Consent for Care and Treatment (Vietnamese)
Medical patients
- Adult Medical Health History (English)
- Adult Medical Health History (Spanish)
- Child Medical Health History
Dental patients
Review our Notice of Privacy Practices
- Notice of Privacy Practices (English)
- Notice of Privacy Practices (Spanish)
- Notice of Privacy Practices (Vietnamese)
- Notice of Privacy Practices (Somali)
MyChart Forms
Print and complete this form to request proxy access to a child's MyChart account (proxy means representing someone else) and give it to the front desk at your child's next appointment at the clinic. Read more about proxy access on the MyChart page.
- MyChart Proxy Access Request Form (English)
- MyChart Proxy Access Request Form (Amharic)
- MyChart Proxy Access Request Form (Khmer)
- MyChart Proxy Access Request Form (Somali)
- MyChart Proxy Access Request Form (Spanish)
- MyChart Proxy Access Request Form (Tigrinya)
- MyChart Proxy Access Request Form (Vietnamese)
Sliding fee discount application
If you do not have health insurance or are underinsured, we can help you understand your options for applying for insurance and other assistance programs available regardless of income or immigration status. One of those programs is our sliding fee discount program based on household size and income. Call to make a free appointment with one of our eligibility specialists. Visit the sliding fee discount program page for application forms.
Behavioral Health
Before your behavioral health phone visit, please click on the links below, answer the questions, and write down your total scores for each questionnaire. Give the two scores to your behavioral health provider during your visit.
You may also complete these questionnaires by printing a paper version:
Nutrition Counseling
Our dietitian nutritionists can help patients of all ages and from all cultures change their eating habits to improve their health. Appointments are free for Neighborcare Health patients.
Please view, download and/or print the materials below as requested by your care team:
- Blood pressure & blood sugar log
- Blood sugar log
- Diabetes type 2 risk test
- Prediabetes handout
- Diabetes care schedule
- Diabetes eye care