We are committed to the privacy of our patients. We protect all health information in compliance with the law. We keep a record of all patient interactions with the clinic, and details of the services provided. Patients may request a copy of their personal health record, and we may amend those records at the patient’s request, if they are found to be inaccurate. We do not disclose protected health information to anyone, unless given permission by the patient, or when the law authorizes or compels us to do so.
The Privacy Practices notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Privacy Practices – English (PDF)
- Authorization for Release of Protected Health Information (Word)
We strive to provide you with the best possible customer service. Please notify us right away if you have a complaint. To submit a complaint, please complete the form below and give to the site manager OR email to email@example.com.
The Patient Forms below can be opened and filled out on your computer, or printed and handwritten before your appointment. You may also fill out the forms when you arrive for your appointment.
- Registration Form (Word)
- Authorizations Form (Word)
- Application for Sliding Fee Scale (Word)
- Patient Health History (Word)
- Pediatric Health History (Word)
- Female Family Planning Health History (Word)