Medical Forms
New Patient Forms to Download

In-Take Registration Form

Health History Form

Mental Health 

Health Assessment

Informed Consent

Privacy Consent Form

Rights + Responsibility

Family Income Certification

Behavioral Health Forms to Download

Patient Information

Patient Screening Form

Consent to Release

Consent to Treat Minor

No Show Policy

Rights Responsibility

Complaints Appeal Form

Dental + Vision Forms to Download

Dental Consent Form

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HEADQUARTERS
420 S. Glendora Avenue  |  West Covina, CA 91790
(626) 919-5724  |  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.
©2006-2020 East Valley Community Health Center. All rights reserved.
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