top of page
Patient Forms
New Patient Forms to Download

In-Take Registration Form

Health History Form

Mental Health 

Health Assessment

Informed Consent

Family Income Certification

Good Faith Estimate

Privacy Consent Form

Rights + Responsibility

Behavioral Health Forms to Download

Consent to Treat Minor

Limits of Confidentiality

No Show Policy

Complaints Appeal Form

Advncd Hlth Care Directive

BH Screening Tool

Consent to Release

Dental + Vision Forms to Download

Dental Consent Form

  • LinkedIn
  • Twitter
  • Facebook
  • Instagram
  • YouTube
HEADQUARTERS
420 S. Glendora Avenue  |  West Covina, CA 91790
(626) 919-4333  |  Fax (626) 919-2084
 

 
East Valley Community Health Center is a Nonprofit 501(c) (3) Federally Qualified Health Center (FQHC) with tax Id # 23-7068586.
©2006-2025 East Valley Community Health Center. All rights reserved.
PRIVACY POLICY
FTCA Badge_web version.jpg
2024 HDR.png
2024 AE.png
bottom of page