New Patient Information
New to Tri-State Community Healthcare Center? Below you’ll find lots of information that will help expedite your wait time. You may download and fill out forms 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
- Pediatric Patients Registration Form
- VFC Eligibility Screening
- Authorization for Alternate Adult/Guardian Clinic Visits
- Pediatric Past Medical History from age 0-17 years of age
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)
Dental Patients
- Adult Dental Health History Form
- Pediatric Dental Health History Form
- Oral Health Risk Assessment
