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
- Medical History (Spanish)
- Request for Medical Services (English)
- Request for Medical Services (Spanish)
- Financial Information Form (English)
- Financial Information Form (Spanish)
All new patients will need to complete all four 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 our Athens 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 our Athens Health Center, along with the necessary payment.
For information on having your pills mailed to you, click here.
Release of Records to/from PPSEO
If you need records to be released to/from PPSEO, please fill this out and return it to your Doctor's Office/PPSEO.
