Patient Forms
If you have an appointment at one of our health centers, print or download the forms you'll need to bring with you and fill them out before your appointment.
*Please use a pen with blue or black ink to complete your forms.
Funding Application Forms
If you are applying for a state funding program, please complete the application form for the state where you live.
- WA - Family Planning Only Services Application Form (ENG)
- WA - Solicitud de servicios exclusivamente para planificación familiar (ES)
Reproductive Health (RH) Program
The Reproductive Health (RH) Program pays for birth control and medical services related to reproductive health.
We do not discriminate. You can get services no matter your citizenship, immigration, documentation status, or gender identity.
- Please fill out this RH Access Fund form to help us decide if you qualify for these services. This information is kept as private as possible.
To learn more visit The Oregon Reproductive Health Program.
To find out if you may qualify for these services, visit The Reproductive Health Client Services page
Other Forms:
- Information Release Form: If you want us to send your medical records to another provider or have another medical provider send us your records, please fill out this form. You can mail, fax or bring it in to the nearest health center location.
Notice of Privacy Practices
- Acknowledgement of Notice of Privacy Practices (ENG)
- Confirmación de Recibo del Aviso Sobre Prácticas de Privacidad (ES)
Notice of Health Information Privacy Practices
- Notice of Health Information Privacy Practices (ENG)
- Notificación de Prácticas de Privacidad de la Información de Salud (ES)
- Thông Bảo Về Thực Hành Quyền Riêng Tự Đối Với Thông Tin Sức Khỏe (Viet)
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Download a free copy here: Get Adobe Reader