Forms

New patients of Health Partners Free Clinic are required to fill out 3 forms, in addition to providing other documents for treatment. You can download and print the forms here to save time and help you prepare for your visit to the Clinic.

Consent to Treat Form

This form gathers important information about your eligibility for care and creates a record that you have consented to medical treatment by Health Partners Free Clinic’s medical staff.
Download form

Confidentiality

This form creates a record that you have been advised of and accept Health Partners Free Clinic’s privacy policy. Your privacy is very important to us; our policy gives you the information on how and when, with your permission, we share your medical history or concerns with others.
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Medical History

This is a very important form that will provide the Clinic’s medical staff with information about you and your health, and help determine current and future healthcare needs.
Download form

Expectations Agreement

This form is a formal agreement between the clinic and the patient as to what we can respectfully expect from each other as care is provided here at Health Partners Free Clinic.

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