Patient Forms

When becoming a patient at NeighborHealth Center, you are required to complete new patient paperwork. This is a necessary part of establishing care at NeighborHealth because it provides our staff with all the information needed to provide you and your family with safe, effective, and complete health care. Please see forms below.

Please complete and print these forms BEFORE you come in for your appointment.

If you are unable to do this ahead of time, please arrive at least 15 minutes before your appointment to complete them.

This form asks for your (or your child’s) personal information.

Este formulario solicita la información personal de usted (o su hijo/a).

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Spanish

This form informs you of our policies at NeighborHealth Center.

Este formulario le informa sobre nuestras políticas en NeighborHealth Center.

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Spanish

If you want anyone else to know or speak about your health information, please list them on this form.

Si desea que otras personas conozcan o hablen sobre su información de salud, por favor, anótelas en este formulario.

If you want anyone else to know or speak about your health information, please list them on this form.

Si desea que otras personas conozcan o hablen sobre su información de salud, por favor, anótelas en este formulario.

English

Spanish

This policy informs you what NeighborHealth needs to care for your child.

Esta política le informa lo que NeighborHealth necesita para cuidar de su hijo.

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Spanish

If you want another adult to bring your child that is not their parent/guardian, please fill out this form.

Si usted quiere que otro adulto que no sea padre o tutor, traiga a su hijo a las citas, por favor, complete este formulario.

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Spanish

Photo witj a Famele Doctor checking an old woman

If you need a form that is not listed on our website, please call our main number at 984-222-8000 and ask to speak with a registration representative. Thank you!

Patient Forms

Patient Registration Form (update yearly)

Patient Commitment Agreement (one time completion)

Authorization to Obtain Health Information (update yearly)

Authorization to Use/Disclose Health Information (update yearly)

Policy for Parents/Guardians of Children at NeighborHealth (one time completion):

Minor Authorization Form (effective through date listed on form)