Patient Information

New Patient Information

New to Tri-State Community Healthcare Center? Below you’ll find lots of information that will help to expedite your wait time, you may download and fill them out at your convenience prior to your first appointment.

Items to bring to your first visit:

  • Completed Forms
  • Photo ID
  • Health Insurance Card (if applicable)
  • Social Security Card (if applicable)
  • All current medications
  • Immunization Records
  • Proof of income for uninsured patients

Pediatric Patients Forms

  • Pediatric Patients Registration Form
  • VFC Eligibility Screening
  • Authorization for Alternate Adult/Guardian Clinic Visits

Adult Patients

  • Patient Registration Form
  • Advance Directive Acknowledgement
  • Patient Consent for Treatment Form
  • Notice of Privacy Practices
  • Medical Record Release Form
  • Behavioral Health Record Release Form
  • Screening Checklist for Contraindications to Vaccines for Children and Teens
  • Screening Checklist for Contraindications to Vaccines for Adults
  • Tuberculosis Questionnaire
  • Income Verification Form
  • Adult Past Medical History (18+ Years)

Pediatric Patients

  • Pediatric Patient Registration Form
  • VFC Eligibility Screening
  • Authorization for Alternate Adult/ Guardian Clinic Visits
  • Pediatric Past Medical History - 0-2 Months
  • Pediatric Past Medical History - 2 - 6 Months
  • Pediatric Past Medical History - 7-12 Months
  • Pediatric Past Medical History - 1 - 2 Years
  • Pediatric Past Medical History - 3-4 Years
  • Pediatric Past Medical History - 5-8 Years
  • Pediatric Past Medical History - 9 - 11 Years
  • Pediatric Past Medical History - 12 - 17 Years

Dental Patients

  • Adult Dental Health History Form
  • Pediatric Dental Health History Form
  • Oral Health Risk Assessment