TUSCARAWAS COUNTY HEALTH DEPARTMENT
  • Home
  • COVID 19
    • COVID-19 Vaccine >
      • COVID-19 Vaccine Information
  • Environmental Health
    • Animal Bite Investigation >
      • Rabies Surveillance
    • Camps, RV, and Recreation Parks
    • Food Safety Program >
      • Food Service / Retail Food Establishment Complaint Form
    • Mosquito Control
    • Nuisances >
      • Mold
      • Bed Bugs
      • Ticks
    • Public Swimming Pools and Spas
    • Solid Waste Program
    • Tattoo and Body Piercing Program
    • Water Safety Program (Well and Septic) >
      • Water Pollution Control Loan Fund
  • Community Health Services
    • CMH-Children with Medical Hanidcaps
    • Communicable Disease Reporting >
      • TB Control Unit
    • Immunizations
    • Reproductive Health and Wellness
    • Rural Health Clinic >
      • Clinic Forms
  • Prevention Services
    • Car Seat Program
    • Cribs for Kids Program
    • Emergency Preparedness >
      • Medical Reserve Corp (MRC)
      • Preparedness Tips
    • Project DAWN >
      • Request A Naloxone Kit
    • Safe Beginnings
    • Safe Communities
    • Tobacco Use Prevention >
      • Ask, Advise, Refer
  • Vital Statistics
    • Birth & Death Certificates
  • Promotion and Community Relations
    • Press Releases
  • WIC (Women, Infant and Children)
  • Employment
  • About Us
    • District Advisory Council
    • Board of Health
    • Administration
    • Public Health Accreditation
    • Current Reports
    • Annual Reports 1940-Present
  • Contact Us
  • Employee Portal
    • Employee Information
    • Employee Directory
    • Personnel Policy Manual
    • Workforce Development >
      • New Employee Trainings
      • Annual Trainings
    • TCHD Position Descriptions
    • 2022 Department Benchmarks
    • Policies & Procedures
    • TCHD Forms >
      • Accounting & Billing Forms
      • Branding Documents
      • Department Wide Forms
      • Clinic Forms
      • Environmental Health Forms
    • Performance Measures
    • Continuous Quality Improvement (CQI) & Performance Management (PM)
    • After Action Reports
    • EH Records

Medical Clinic Forms

Please click on the appropriate link below to be taken to a fillable form. You can then email the completed form to the clinic and it should be here when you arrive, or you can print the form and bring it with you.
  1. To email the form: Click on the link in the form to open your email program and send the completed form to the TCHD Clinic.
  2. To print the form: Click on the "Print" button. 

NOTE: In the event that you are unable to email the form, please print the form and bring with you to your appointment.  Thank you!

Annual Screening Form
Childhood Immunization Form
Influenza & Pneumonia Vaccine Form
Refusal of Treatment Form
Reproductive Life Plan
Tobacco Screening Form

Patient Financial Forms
Patient Payment Agreement
Sliding Fee Discount Application
Insurance Waiver Form
Release of Information Form
  • Home
  • COVID 19
    • COVID-19 Vaccine >
      • COVID-19 Vaccine Information
  • Environmental Health
    • Animal Bite Investigation >
      • Rabies Surveillance
    • Camps, RV, and Recreation Parks
    • Food Safety Program >
      • Food Service / Retail Food Establishment Complaint Form
    • Mosquito Control
    • Nuisances >
      • Mold
      • Bed Bugs
      • Ticks
    • Public Swimming Pools and Spas
    • Solid Waste Program
    • Tattoo and Body Piercing Program
    • Water Safety Program (Well and Septic) >
      • Water Pollution Control Loan Fund
  • Community Health Services
    • CMH-Children with Medical Hanidcaps
    • Communicable Disease Reporting >
      • TB Control Unit
    • Immunizations
    • Reproductive Health and Wellness
    • Rural Health Clinic >
      • Clinic Forms
  • Prevention Services
    • Car Seat Program
    • Cribs for Kids Program
    • Emergency Preparedness >
      • Medical Reserve Corp (MRC)
      • Preparedness Tips
    • Project DAWN >
      • Request A Naloxone Kit
    • Safe Beginnings
    • Safe Communities
    • Tobacco Use Prevention >
      • Ask, Advise, Refer
  • Vital Statistics
    • Birth & Death Certificates
  • Promotion and Community Relations
    • Press Releases
  • WIC (Women, Infant and Children)
  • Employment
  • About Us
    • District Advisory Council
    • Board of Health
    • Administration
    • Public Health Accreditation
    • Current Reports
    • Annual Reports 1940-Present
  • Contact Us
  • Employee Portal
    • Employee Information
    • Employee Directory
    • Personnel Policy Manual
    • Workforce Development >
      • New Employee Trainings
      • Annual Trainings
    • TCHD Position Descriptions
    • 2022 Department Benchmarks
    • Policies & Procedures
    • TCHD Forms >
      • Accounting & Billing Forms
      • Branding Documents
      • Department Wide Forms
      • Clinic Forms
      • Environmental Health Forms
    • Performance Measures
    • Continuous Quality Improvement (CQI) & Performance Management (PM)
    • After Action Reports
    • EH Records