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.
Read and Sign form
Read and fill out form
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.
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.
This is a survey created by the Centers for Disease Control (CDC) to screen individuals for their risk of developing diabetes. Health Partner Free Clinic utilizes this screening to help those that may not have active diabetes, but would benefit from medical care before becoming diabetic.
Take the Survey