Primary Care Clinics
Forms for our primary-care clinic patients. New patients should start with registration.
Advance Directive
This form helps us understand who can help you make medical decisions if you should lose decision making capacity.
Consent for Treatment of Minors & Release of Information
If the new patient is a minor, this form must be completed by a guardian.
New/Annual Patient Registration
Complete this form as a new patient. Expires twelve (12) months from the date signed and must be resubmitted annually.
Notice of Privacy Practices
This notice describes how your medical info may be used, disclosed, and accessed by you as the patient.
Patient – Provider Agreement
This document outlines expectations between the patient and providers at Shalom Health Care Center.
Patient Intake Checklist
Complete this form after completing the patient registration form.
Patient Rights & Responsibilites
This document informs you about your rights to quality treatment, privacy, and participation in decisions and your responsibilities such as providing accurate information and adhering to prescribed treatments.
School-Based Clinics
Consent and enrollment forms for students — available in English, Spanish, and Haitian Creole.
SBC Consent to Treat
This form must be completed before services can be provided to the student.
SBC Med Administration Consent
Complete this form if it becomes necessary for a student to take medication or receive treatment during the school day.
Need help with a form? If you have questions or would like assistance completing any document, contact us — our front-desk staff will be glad to help at your next visit.
English 
Español de México 
Haitian Creole