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 (12/8/23) - English (Submit Online | Printable Version)
- Consent to Care Form - Spanish (Submit Online | Printable Version)
- Intake Form (6/1/22) - English (Submit Online | Printable Version)
- Intake Form - Spanish (Submit Online | Printable Version)
Other Forms (if needed)
- Medical Records Request Form (Submit Online | Printable Version)
- Release of Information Form - English (Submit Online | Printable Version)
- Release of Information Form - Spanish (Printable Version)
- Revocation of Consent to Release Information Form (Submit Online | Printable Version)
- Parent or Court-Appointed Guardian Request for MyChart Caregiver Access (for minor patients or adult patients with guardian) (Submit Online | Printable Version)
- Request for MyChart Caregiver Access (for adult patients) (Submit Online | Printable Version)
Patient Handbooks (Revised 1/10/23)
The handbook includes Patient Rights and the Grievance Policy.
Fee Schedule & Sliding Fee Scale for 2025
- Fee Schedule Agreement Form (12/9/24) | Español
- Sliding Fee Scale - FQHC & Title X | Español
- Sliding Fee Scale - Ryan White Program | Español
Notice of Privacy Practices
Notice of Nondiscrimination
