TUSCARAWAS COUNTY HEALTH DEPARTMENT
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    • Employee Information
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    • Workforce Development >
      • New Employee Trainings
      • Annual Trainings
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    • Performance Indicators & Strategic Plan
    • Policies & Procedures
    • TCHD Forms >
      • Accounting & Billing Forms
      • Branding Documents
      • Department Wide Forms
      • Clinic Forms
      • Environmental Health Forms
    • Continuous Quality Improvement (CQI) & Performance Management (PM)
    • After Action Reports
    • EH Records

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
Picture
  • Home
  • Birth & Death Certificates
  • 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 Quality Program (Well and Septic) >
      • Lead Safety
      • Operation and Maintenance Program
      • Water Pollution Control Loan Fund
  • COVID-19 Information
    • COVID 19
    • COVID-19 Vaccine >
      • COVID-19 Vaccine Information
  • Bureau of Community Health Services
    • Community Health Worker - Bridges to Wellness Program
    • Medical Services >
      • Medical Services
      • Reproductive Health and Wellness
      • Immunizations
      • Medical Service Forms
    • Measles
    • Communicable Disease Reporting >
      • TB Control Unit
    • CMH-Complex Medical Help Program
  • 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
    • Traffic Safety
    • Falls Among Older Adults - Injury Prevention
    • Child Injury Prevention
    • Spread Joy. Not Germs.
    • Creating Healthy Communities
    • Tobacco Use Prevention >
      • Ask, Advise, Refer
  • 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
  • Public Notices
  • Employee Portal
    • Employee Information
    • Employee Question/Suggestion Box
    • Employee "Thank You" Form
    • Peer Recognition Form
    • Employee Directory
    • Personnel Policy Manual
    • Workforce Development >
      • New Employee Trainings
      • Annual Trainings
    • TCHD Position Descriptions
    • Performance Indicators & Strategic Plan
    • Policies & Procedures
    • TCHD Forms >
      • Accounting & Billing Forms
      • Branding Documents
      • Department Wide Forms
      • Clinic Forms
      • Environmental Health Forms
    • Continuous Quality Improvement (CQI) & Performance Management (PM)
    • After Action Reports
    • EH Records