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 & All Required Forms (English | Español)

• Adult Health History Form
  English | Español
• Prescription Refill Request
  English | Español
• Controlled Substance Prescribing Practices
  English | Español

Pediatric Forms

Download Pediatric Primary Care & All Required Forms (English | Español)

• Pediatric Health History Form
  English | Español
• Prescription Refill Request
  English | Español
• Controlled Substance Prescribing Practices
  English | Español

Adult Psychiatric Medical Forms

Download Adult Psychiatric Medical & All Required Forms (English | Español)

• Adult Health History Form
  English | Español
• Prescription Refill Request
  English | Español
• Controlled Substance Prescribing Practices
  English | Español

Pediatric Psychiatric Medical Forms

Download Pediatric Psychiatric Medical & All Required Forms (English)

• Pediatric Health History Form
  English | Español
• Prescription Refill Request
  English | Español
• Controlled Substance Prescribing Practices
  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

Douglas County

Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)

Coos County

Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)

Curry County

Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)

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

Douglas County

Download Substance Use & All Required Forms (English | Español)

Coos County

Download Substance Use & All Required Forms (English | Español)

Josephine County

Download Substance Use & All Required Forms (English | Español)

Curry County

Download Substance Use & All Required Forms (English | Español)