Patient Forms

Make Your Visit As Smooth & Efficient As Possible

Conveniently access our new patient forms to make your first visit to PureView Health Center as smooth and efficient as possible. Click the appropriate button to access our forms in the Portable Document Format (PDF), which requires Adobe’s Acrobat Reader.

Save time and avoid unnecessary delays

1. Find the appropriate form
2. Print the form
3. Fill out the form
4. Bring the forms with you to your appointment
   

Intake Forms

Patient Information – PureView Health Center (PDF Version)

School-Based Care

School-Based Care Intake Form

Automated Application Request

Other Forms

Sliding Fee Discount Program Application (PDF Version)

Medical Records Release of Information (PDF Version)

Medical Records Change Request Form (PDF Version)

General Authorization For Treatment (PDF Version)

HCH Enrollment Form (PDF Version)

Affidavit of Financial Status (PDF Version)

Welcome Brochure 2023 / PCMH Information (PDF Version)