Patient Forms
Save time by filling out your patient forms ahead of your appointment.
Patient Forms
If you are new to Signature Health, you’ll need to fill out our new patient paperwork. You have the option to fill out the forms before your appointment, to save time. We also use DocuSign to send forms via email for patients to complete and sign electronically.
To complete your patient forms ahead of time, please print the below forms, fill them out, and bring them to your first appointment.
New Patient Forms
- Consent to Care Form - English
- Consent to Care Form - Spanish/Español
- Intake Form - English
- Intake Form - Spanish/Español
Other Forms (if needed)
- Medical Records Request Form - English
- Release of Information Form - English
- Release of Information Form - Spanish/Español
- Revocation of Consent to Release Information Form - English
- Parent or Court-Appointed Guardian Request for MyChart Caregiver Access Request Form - English (for minor patients or adult patients with guardian)
- MyChart Caregiver Access Request Form - English (for adult patients)
Patient Handbooks (Revised 1/10/23)
The handbook includes Patient Rights and the Grievance Policy.
Fee Schedule & Sliding Fee Scale for 2026
- Fee Schedule Agreement Form (12/9/24) | Español
- Sliding Fee Scale - FQHC, Title X, & Dental | Español
- Sliding Fee Scale - Ryan White Program | Español
Notice of Privacy Practices
Notice of Nondiscrimination
