Forms and Information
Download and print paper copies of some of the most helpful and most often used forms at Share Ourselves. Complete your new patient registration forms before your first appointment, fill out a request for medical records, apply for financial assistance, and more!
English
New Patient Forms
- New Patient Registration Form
- General Consent for Treatment
- Right to Make Decisions
- California Advance Health Care Directive
- Paying for Services Agreement
- 2024 Sliding Fee Scale
- Sliding Fee Discount Application
- Bill of Rights and Duties
- Code of Conduct Agreement
- Share Ourselves Notice of Privacy Practices
- Acknowledgements
- Full New Patient Registration Packet
(Note: This packet contains all the documents above, including the California Advance Health Care Directive form, which makes it total 48 pages. If you do not wish to print the California Advance Health Care Directive, use the links above to print the other new patient forms individually instead.)
Financial Patient Forms – Medical, Dental or Behavioral Health
- Sliding Fee Discount Application
- Financial Hardship Application
- Self Declaration of Income
- Documents to Confirm Eligibility
Requests and Consents
- Request and Authorization for Use or Disclosure of Health Information
- Right of Access for Designated Individuals
Patient Education & Self-Management Materials
- Blood Pressure Log
- Breast Cancer Screening
- Colorectal Cancer Screening
- Diabetes
- High Blood Pressure
- High Blood Pressure Management
Español
Formularios para nuevos pacientes
- Formulario de Registro del Paciente
- Consentimiento General para Recibir Tratamiento
- Su derecho a tomar decisiones sobre el tratamiento médico
- Instrucción anticipada de atención de salud de California
- Pago por los Servicios — Acuerdo
- 2024 Programa de Descuento
- Solicitud de Descuento por Tarifa Variable
- Declaración de Derechos y Obligaciones
- Código de Conducta — Acuerdo
- Aviso de prácticas de privacidad
- Acuse de Recibo
- Paquete de registro completo para nuevos pacientes
(Nota: Este paquete contiene todos los documentos de arriba, incluyendo La Directiva Avanzada de Salud de California, lo cual hace un total de 52 páginas. Si no desea imprimir la Directiva Avanzada de California, use los enlaces de arriba para imprimir las nuevas formas para los pacientes individualmente.)
Formularios financieros para pacientes: salud médica, dental o conductual
- Solicitud de Descuento por Tarifa Variable
- Share Ourselves solicitud de dificultad financiera
- Declaración Personal de Ingresos del Paciente
- Documentos para confirmer Eligibilidad