Download Registration Forms Here!
Patient Consent Form
Read our Privacy Practices Policy
Release of Medical Records
Patient Health Questionnaires
Depression Screening PHQ-9
Pediatric Medical History
Dental Medical History
for patients 13 & older
for patients 17 & younger
for all Dental patients
Sliding Fee Discount Program
If you are applying for our Sliding Fee Discount Program, you will need to complete the following:
Sliding Fee Discount Application Download
List all family members and dependents living in your household.
A Family is one or more persons living in one dwelling place who are related by blood, marriage or law.
A Dependent is someone who lives in your household and qualifies as a dependent for federal tax purposes.
Proof of Income (POI)
You will also need proof of income for all working family members for the past 30 days. We accept check stubs, SSI or Disability award letters, Child Support or Alimony orders or Unemployment compensation. If you do not have any of these, the following alternative options may apply:
Employment Verification Form Download
If you do not receive check stubs or have recently started a new job, please have your employer complete. This form must be dated within fourteen (14) days of your scheduled appointment.
Self-Employment Declaration Form Download
This is a signed form indicating your net income for the past month. You will also need to provide all of the following:
- Pages 1 & 2 from Current Year Tax Returns
- Schedule C, E or F from Current Year Tax Returns
- Bank statement from the past 30 days
Alternative Income Form Download
This is a signed form indicating that someone is supporting you at this time. To be eligible to use this form you must be:
- Eighteen (18) or older
- Supported by another individual (cannot be a spouse)