You can print these three forms, fill them out, and bring them with you to your visit. Please fill out the forms with black ink.
- Patient Registration (English)
- Patient Registration (Spanish)
- Medical History
- Request for Provision of Medical Services (English)
- Request for Provision of Medical Services (Spanish)
All new patients will need to complete all three forms before their first visit, either ahead of time or after arriving at the Health Center.
Returning patients should update their Patient Registration or Medical History form if any information has changed since their last visit.
The information you provide on these forms is strictly confidential.
Other Forms
Permission for Pill Pickup
Don't have time to pick up your supplies? You can send a friend to pick them up for you. Just print this form and fill it out. Then have your friend bring it to your regular PPCO Health Center, along with the necessary payment.
Don't have time to pick up your supplies? You can send a friend to pick them up for you. Just print this form and fill it out. Then have your friend bring it to your regular PPCO Health Center, along with the necessary payment.
For information on having your pills mailed to you, click here.
Release of Medical Information
Do you need your Records Released to PPCO or from PPCO, please fill out this form and submit either to your doctor or PPCO.
