:::: PATIENT FORMS ::::

Patient Forms

We offer these forms which can be saved and/or printed for your convenience:

Sliding Fee Scale Brochure
Patient Information Form
New Patient Registration Packet - Ages 0-17
New Patient Registration Packet - Adults
Treatment of Minors Consent Form
Records Release
Discount Prescription (340B) Program Brochure
Good Faith Estimate

Billing Agreement
Sliding Fee Scale Application
CHCGD Printable Brochure
Patient Resource List
CHCGD Notice of Privacy Practices
DPS & Mobile Health Unit Consent Form
DPS Mobile Health Unit Brochure

Patient Forms

To Schedule An Appointment
Call (937) 461-6869 or click to the link for Self-Scheduling

Testimonials

Patient Forms

To Schedule An AppointmentCall (937) 461-6869 or click to the link for Self-Scheduling

Testimonials

To Schedule An Appointment
Call (937) 461-6869 or click to the link for Self-Scheduling