Medical Service 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!

New Patient Forms

Patient Medical History Form

Patient Medical History Form- Spanish

Patient Policies and Procedures Acknowledgement Form 2023-02

Notice of Privacy Practices Policy 2023-03

Acknowledgement of Reciept of Privacy Practices form 2023-03

Patient Financial Forms

sliding fee discount policy 2023-04

Sliding Fee Discount Application form 2023-04

Medicare Beneficiary Screening Form 2023-09

Patient Election to Self Pay for Services Form 2023-05

Physical Exam Flat Rate Fee Form

General Patient Forms

Refusal to Consent for Treatment Form 2023-11

Authorization For Release of Medical Information Form 2023-11

Unaccompanied Minor Form

Cleveland Clinic Medical Release Form

Immunization (Vaccine) Forms

Flu/Pneumonia/RSV/COVID Vaccine Form

VACCINE ELIGIBILITY FORM

Reproductive Health and Wellness Patient Forms

Reproductive Life Plan

Notice of Lab Services

BCCP Eligibility form