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Forms

To become a CHA patient, please download and complete the following forms and bring them in person to any of our 6 Health Centers to be eligible to schedule an appointment:

For All Patients

Patient Welcome Packet  (Spanish)

Patient Welcome Packet (English)

For Adult Patients

English

  1. Registration Form (English Fillable)
  2. Medical and Dental History and Physical Packet (English Fillable) 
  3. Combined Signature Forms (English Fillable)

Spanish

  1. Registration Form (Spanish Fillable)
  2. Medical and Dental History and Physical Packet (Spanish Fillable)
  3.  Combined Signature Forms (Spanish Fillable)

For Patients Who Are Children

English

  1. Registration Form (English Fillable)
  2. Medical and Dental History and Physical Pediatrics (English Fillable) 
  3. Combined Signature Forms (English Fillable)

Spanish

  1. Registration Form (Spanish Fillable)
  2. Medical and Dental History and Physical-Pediatrics (Spanish Fillable) 
  3. Combined Signature Forms (Spanish Fillable)

 

Sliding Scale Form

If you are uninsured you can review a copy of our sliding scale fee and guidelines? See here for sliding scale fee guidelines.

To apply for the Sliding Scale Fee, please fill out the form below and bring it with your other forms the day of registration

  1. Sliding Scale Fee Application (English and Spanish)

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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.

Still confused on how to make an appointment? For instructions click here

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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