Patient Forms | EVCHC Website
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Patient Forms
New Patient Forms to Download

In-Take Registration Form

Health History Form

Mental Health 

Health Assessment

Informed Consent

Family Income Certification

Good Faith Estimate

Privacy Consent Form

Rights + Responsibility

Behavioral Health Forms to Download

Consent to Treat Minor

Limits of Confidentiality

No Show Policy

Complaints Appeal Form

Advncd Hlth Care Directive

BH Screening Tool

Consent to Release

Dental + Vision Forms to Download

Dental Consent Form

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HEADQUARTERS
420 S. Glendora Avenue  |  West Covina, CA 91790
(626) 919-4333  |  Fax (626) 919-2084
 

 
East Valley Community Health Center is a Nonprofit 501(c) (3) Federally Qualified Health Center (FQHC) with tax Id # 23-7068586.
©2006-2022 East Valley Community Health Center. All rights reserved.
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