Registration and Financial Forms

Patient Registration Form (Enter name and date of birth, then enter any changed information)

Financial Responsibility Form (Enter name and date of birth, then enter any changed information)

Medical History Form (For adults: Update every 3 years—recommended)

Pediatric Medical History Form (For children. Update every 3 years—recommended)

Minor Consent Form (complete for each child that may be brought in by someone other than a parent or legal guardian)

Workers’ Compensation Data Worksheet Form (complete for injuries related to employment)

Automobile and Casualty Insurance Data Worksheet Form (complete for injuries related to an accident)

Scheduled for a TeleVisit? See: Patient Portal / Healow App and Doxy.me
TriValley Primary Care Offices are OPEN! Call for an appointment or a Televisit!
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