Registration Forms

Download, print, and fill out the forms that you will need for your appointment.

• ALL patients need to fill out forms 1, 2, and 3.
• Fill out additional forms as instructed by Public Health Nursing Staff.
• Call for an appointment. (Find a Public Health Center)

PLEASE DO NOT EMAIL the forms; they contain your Protected Health Information.

1. Client Registration Form
2. DHSS Acknowledgement of Privacy Notice (06-5876) 09-03
3. DHSS Notice of Privacy Practices

• Release of Information
• Reproductive Health History - Female
• Reproductive Health History - Male