Patient Forms
Primary Care Forms
If you need assistance or would like us to mail you the forms, please call our office at (541) 492-4550.
Adult Forms
Download Adult Primary Care New Patient Forms (English | Español)
Pediatric Forms
Download Pediatric Primary Care New Patient Forms (English | Español)
Psychiatric Medical Services Forms
If you need assistance or would like us to mail you the forms, please call our office at (541) 492-4550.
Adult Forms
Download Adult Psychiatric Medical Services New Patient Forms (English | Español)
Pediatric Forms
Download Pediatric Psychiatric Medical Services New Patient Forms (English | Español)
Mental Health Forms
If you need assistance or would like us to mail you the forms, please call the office nearest you: Douglas County (541) 440-3532, Coos County (541) 751-0357, Curry County (877) 408-8941
Adult Forms
Download Adult Mental Health New Patient Forms (English | Español)
Pediatric Forms
Download Pediatric Mental Health New Patient Forms (English | Español)
Assertive Community Treatment
Assertive Community Treatment (ACT) Universal Referral Form
Email completed form to: [email protected], [email protected], and [email protected]
Substance Use Treatment Forms
If you need assistance or would like us to mail you the forms, please call the office nearest you: Douglas County (541) 492-0152, Coos County (541) 751-0357, Josephine County (541) 474-1033, Curry County (877) 408-8941
Adult Forms
Download Adult Substance Use Treatment Services New Patient Forms (English | Español)
Pediatric Forms
Download Pediatric Substance Use Treatment Services New Patient Forms (English | Español)
Other Forms & Information
Notice of Privacy Practices
English | Español
Financial Discount Application
English | Español
Prescription Refill Request
English | Español
Controlled Substance Prescribing Practices
English | Español
Audio Video Recording Consent
English | Español
Voter Registration
English | Español
Media Release Form
English
This health center receives U.S. Department of Health and Human Services (HSS) funding and has U.S. Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.