New Patient Forms
Prior to your medical or dental appointment, please download and complete the following forms in each section and bring them in person. These forms will be available at your appointment if you are unable to download and print at home.
For Adult Medical and Dental Patients
For Pediatric Medical and Dental Patients
- Registration Form (English)
- Pediatric Health History (0-11yr) (English)
- Pediatric Health History (12-18yr) (English)
- Registration Form (Spanish)
- Pediatric Health History (0-11yr) (Spanish)
- Pediatric Health History (12-18yr) (Spanish)
Sliding Fee Scale Application and Guidelines
Please fill out the sliding fee scale application and bring it with your other forms on the day of registration.
You can review a copy of our 2021-2022 sliding scale fee and federal guidelines.
Para consultar Aviso de Política de Privacidad de Community Health Alliance. Esta notificación describe cómo puede utilizarse y divulgarse su información médica, y cómo puede acceder usted a esta información. Revísela con cuidado.