Health Forms
Appointment wait times may vary depending on the number of walk-in patients present and the types of service required. To ensure the shortest delay, please download the appropriate forms and complete them prior to your visit.
All new/first time patients are required to fill out the following two forms:
Notice of Health Information Privacy HIPAA
Notice of Health Information Privacy HIPAA (Spanish)
Request for Medical Services
Request for Medical Services (Spanish)
All new/first time patients scheduled for an examination are required to complete a Self-Medical History form. Existing patients should also complete this form if its been over a year since your last visit.
Female Self-Medical History
Female Self-Medical History (Spanish)
Male Self-Medical History
Male Self-Medical History (Spanish)
For those patients who qualify, Take Charge applications must be completed in the Health Center at the time of visit. You may qualify if you are a Washington resident, U.S. citizen and present and verify:
Your birth certificate or passport;
Your Social Security card or green card (& 5 years residency);
Your income level; and
You have no other Medicaid coverage.
More information regarding the Take Charge program is available here.
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