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