Patient Forms

If you are a new patient please print and complete the Clinic Patient health history form. This will speed the process and allow us to see you sooner. If you are not able to print you are welcome to fill out the appropriate paperwork before check-in. 

If you plan on completing the forms before your appointment please plan to arrive at least 10 minutes early so that you are able to complete the form.

New Patient Paperwork

If you are new to our clinic please complete the following paperwork: New Patient Paperwork 

Patient Privacy Notice

If you are new to our clinic please read over the CHCCC Notice of Privacy Practices. Know your rights as a patient. We encourage you to ask us any questions you have regarding this notice. 

Financial Support Verification Form

If you are interested in our Sliding Discount Fee and are not currently employed and do NOT have insurance, please complete this form.

CHCCC Patient Assistance Program No Income Financial Support Form 

Questions?

If you have any immediate questions please call us at 620-221-3350.

If it is a question regarding the paperwork please leave it blank and ask our receptionist before your appointment.

Thank you and we look forward to seeing you!