Release of Information Authorization Form

Medical Dental


Medical History Form

Pediatric Adult Male Adult Female


Other Forms

Patient Comment Form Sliding Fee Application

Bring to Your Visit

  • Photo I.D.
  • Insurance Card
  • Containers of current medications, vitamins & supplements
  • Sliding fee scale applicants – proof of income
  • Release of Information (ROI) form
Download ROI Form

All Updates

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

HRSA National Health Service Corps Site