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Forms

To apply to become a CHA patient please bring the following completed forms to your appointment.

To review CHA’s Notice of Privacy Policy please see here. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Para consultar Aviso de Política de Privacidad de CHA por favor vea aqui. Esta notificación describe cómo puede utilizarse y divulgarse su información médica, y cómo puede acceder usted a esta información. Revísela con cuidado.

Sliding Scale Form

To review a copy of our sliding scale fee and guidelines please see here.

For Adults Patients Only

For Patients Who Are Children Only

Note: These forms are in both English and Spanish.

Become a Patient

Call us now to schedule an appointment
at a location near you.

Thank you for being my doctor!

Your clinic helps so many people and moves them through very efficiently.  I never mind waiting because I know you are helping someone.  And, when you come in to see me you always give me your full attention, as if I am your only patient.  Your good will and positive intent always shine through. Thank you for being my doctor.

Steven H.

I feel like I just walked in and won the lottery

I feel like I just walked in and won the lottery…I lost one tooth 2 years ago and I was heartbroken and said I never wanna lose a tooth again. I have been so scared that I would not be able to afford my teeth and now I know I can! I am so so so happy! Thank you thank you thank you from the bottom of my heart!

Michelle
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