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 All Patients

Combined Signature Forms (Spanish Fillable) 

Registration Form (Spanish Fillable)

Combined Signature Forms (English Fillable)

Registration Form (English Fillable)

Patient Welcome Packet  (Spanish)

Patient Welcome Packet (English)

For Adult Patients

• Medical and Dental History and Physical Packet (English Fillable) 
• Medical and Dental History and Physical Packet (Spanish Fillable)

For Patients Who Are Children

• Medical and Dental History and Physical-Pediatrics (Spanish Fillable) 
• Medical and Dental History and Physical Pediatrics (English Fillable)