Registration Forms
The following forms can be printed and filled out before your appointment:
Patient Registration Forms
English
Spanish
Patient Confidential Communications
English
Spanish
Consent to Treat, Agreement to Charges, HIPAA Notice, and Proxy
(please complete if patients is under 18.
English
Spanish
Dax Consent
English
Spanish
Immigration Exam – Patient Information
What To Bring To The Examination. Bring the following to your medical examination: Form I-693, Report of Medical Examination and Vaccination Record. Government-issued photo identification, such as a valid passport or driver’s license
I693: Report of Immigration Medical Examination and Vaccination Record | USCIS
English
Translated Versions
Spanish, Arabic, Nepali, French, Dari, Pashto, Swahili, Kinyarwanda, Ukrainian
Telehealth Consent
English
Spanish
FTCA Notice
English
Spanish
Sliding Fee Application
Please complete this application if wish to apply for a discount. Verification of income will be needed. Examples of acceptable VOI includes (paycheck stubs, W2s, Social Security letter, Unemployment Letter, letter from your employer.
English
Spanish
Waiver and Consent Form for Clark County School Clinic
(This form is only for our Clark County School Based Clinic)