*Required fields are marked with an asterisk.

Prepare for Visit

Complete the following forms before coming in for your next visit


  TO SUBMIT ELECTRONICALLY

New Patient Registration Form

Meridian Schools Clinic New Patient Registration

Established Patient Registration Form

2018 Sliding Fee Application

2018 Sliding Fee Additional Information

Authorization to Use Or Disclose Protected Health Information


TO UPLOAD
                         

TO PRINT, COMPLETE AND BRING INTO THE OFFICE


New Patient Paperwork

Established Patient Registration Form

Meridian Schools Clinic New Patient Packet 

Meridian Schools Clinic Established Patient Registration Form        

Consent to Treat Minor     

               

Sliding Fee Applications

2018 Sliding Fee Application (English)

2018 Sliding Fee Application (Spanish) 

2018 Sliding Fee Application (Arabic)
        
      

Authorization Forms

MyFMHC Proxy Consent Form

Authorization to Release Protected Health Information (English)

Authorization to Release Protected Health Information (Spanish)




FORMULARIOS ELECTRONICOS EN ESPANOL

Formulario de Inscripcion de Paciente Nuevo

Formulario de Registro del Paciente Establecido 
Aplicacionde Bajos Recursos 2017

Informacion addicional para aplicacion de bajos recursos

AutorizaciónPara Usar O Revelar Información Médica Protegida

           


PARA IMPRIMIR, COMPLETAR Y ENTREGAR A LA OFICINA
           

Formulario de Inscripcion de Paciente Nuevo 

Formulario de Registro del Paciente Establecido                      

Paquete de Incripcion de Paciente Nuevo Clinica Escolar

Paquete de Registro de Paciente Establecido Clinica Escolar      

Consentimiento para Tratar Menores