Patient Forms

Forms for New Patients

• Nondiscrimination Policy
• CAIR Immunization Registry
• Vaccine Policy
• PCHA Notice of Privacy Practices
• Privacy Notice Signature Page
• Family History
• MyChart Proxy
• Conditions of Registration

Forms for Established Patients

• ADHD Packet
• ADHD Questionnaires
• California State Health Exam Form
• Caretaker Authorization Form
• Preschool Form
• Over 18 year old Patient Information Form
• Authorization for Release of Health Information Form - English
• Authorization for Release of Health Information Form - Spanish

Well Visit Questionnaire Forms

• 2 Week Visit
• 1 Month Visit
• 2 Month Visit
• 4 Month Visit
• 6 Month Visit
• 9 Month Visit
• 12 Month Visit
• 15 Month Visit
• 18 Month Visit
• 2 Year Visit
• 2.5 Year Visit
• 3 Year Visit
• 4 Year Visit
• 5 Year Visit
• 6 Year Visit
• 7 Year Visit
• 8 Year Visit
• 9-11 Year Visit
• 12-17 Year Visit
• 18 and over Year Visit
• MCHAT English
• MCHAT Spanish