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 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, and creates a record that you have consented to medical treatment by Health Partners Free Clinic’s medical staff.
Read and Sign 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.
Read and fill out form

Patient Demographics Form

This form provides the Clinic with some basic information utilized to create a patient profile. This form will also capture some financial information which helps our staff ensure your access to our healthcare resources.
Read and fill out form

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.
Read and fill out form

Prediabetes Survey

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