close

Preparing for Your Visit (Forms and Hints)

When you first visit the health center, our staff may ask you to fill out a number of forms.  These materials will help us to know how best to serve you and will give you a chance to let us know your health concerns.  You can download forms here to save yourself time at the health center.

These forms are PDF documents, which require Adobe Acrobat Reader to open and print.  This is a free program and is easy to install. If you do not have Acrobat Reader, please install it using this link.

Printing, completing, and bringing forms with you such as your medical history and demographic information, should help shorten your visit with us. The information you provide on all of these forms and your visit is strictly confidential (see HIPAA Privacy Statement).

Please make sure all forms are filled out in blue or black ink as we cannot accept forms filled out in pencil.  Please do not sign these forms until you come to the health center.


New Patients (Nuevos Pacientes)
If you are a new patient, you will need to complete these forms.  If you do not bring them with you, you will be asked to fill them out at the health center.
(Si es usted un nuevo paciente, por favor, complete el siguiente formulario. Si no lo trae consigo, se le pedira, que se llene en el Centro de Salud.)

Existing Patients (Pacientes ya existentes)
Have you moved within the past year?  Do you have a new phone number?  Maybe you have had a marital status change since your last visit with us.
If yes, please print and complete only those portions of the the form where the information you previously provided us has changed.
(¿Se ha mudado usted recientemente?  ¿Acaso tiene usted un nuevo numero telefonico?  ¿Ha habido algun cambio en su estado marital desde su ultima visita? Si la respuesta es si, por favor, complete solo la sección del formulario, que refleje dichos cambios.)

Medical History Form:  Your basic medical information.  Please complete the form no later than 2 days prior to your arrival at the health center.
Historia Medica Inicial: Por favor complete la informacion medica basica, a mas tardar 2 dias antes de su llegada al Centro de Salud.

Demographics Form:  Name, address, phone numbers, etc.
Datos Demograficos:  Nombre, dirección, números de teléfono, etc.


Other Ways to Prepare (Otras formas de prepararse)

Another way you can prepare for your visit is to make a list of your questions and concerns. Our staff members are happy to answer all of your sexual health questions, but we can't answer if you don't ask. Writing them down can help you remember everything you wanted to ask while you're at the health center.
(Otra forma que tiene usted para su visita es hacer una lista de sus preguntas y preocupaciones. Nuestro personal amablemente estara dispuesto de responderle todas sus preguntas relacionadas con la salud sexual, pero no se podra hacer, si usted no es capaz de preguntar. Enumerarlas pueden ayudarle a usted a recordar todo, mientras esta en el centro de Salud.) 


 

 

 

 


Find A Health Center

or

Or Call
1-800-230-PLAN