PATIENT REGISTRATION FORMS

The forms listed below are provided to allow those who wish to complete their new patient paperwork at home to do so. You may download and fill them out at your convenience prior to your first appointment. Bring the completed forms, a photo ID and your insurance card(s) with you to your appointment. Our Customer Service Representative will enter your information into our Electronic Health Record System.

 

You will need Adobe Acrobat Reader to read and print these forms. You can download Adobe Acrobat Reader here.

 

Arabic Forms 

       

Borrego Health Notice of Privacy Practices- Arabic

Screening Checklist for Contraindications to Vaccines for Children and Teens - Arabic

Screening Checklist for Contraindications to Vaccines for Adults - Arabic

** A copy of the immunization record will also be needed for all adults and children.

Please, bring all immunization records to every visit with us.

 

English Forms

 

Medical

Advance Directive Acknowledgement 

Behavioral Health Record Release Form

Borrego Health Consent Form

Borrego Health Notice of Privacy Practices 

General Consent for Medical Treatment 

Medical Record Release Form 

Patient Registration Form 

Screening Checklist for Contraindications to Vaccines for Children and Teens 

Screening Checklist for Contraindications to Vaccines for Adults 

Tuberculosis Questionnaire 

Additional Family Members Form

Adult Past Medical History (18+ Years)

Pediatric Past Medical History - 0-2 Months

Pediatric Past Medical History - 2 - 6 Months

Pediatric Past Medical History - 7-12 Months

Pediatric Past Medical History - 1 - 2 Years

Pediatric Past Medical History - 3-4 Years

Pediatric Past Medical History - 5-8 Years

Pediatric Past Medical History - 9 - 11 Years

Pediatric Past Medical History - 12 - 17 Years

Dental

Adult Dental Health History Form

Child Dental Health History Form

** A copy of the immunization record will also be needed for all adults and children.

Please, bring all immunization records to every visit with us.

 

Spanish Forms

 

Medical

Autorización de Uso o Revelación de Información de Salud Personal

Consentimiento General Para el Tratamiento Medico

Cuestionario sobre Tuberculosis

Formulario de Registro para Pacientes 

Formulario para Miembros Familiares Adicionales

Historial del Pasado Medico para Adultos (18+ años)

Historial del Pasado Medico para Niños de 0 a 2 meses

Historial del Pasado Medico para Niños de 2 meses a 6 meses

Historial del Pasado Medico para Niños de 7 meses a 12 meses

Historial del Pasado Medico para Niños de 1 años a 2 años

Historial del Pasado Medico para Niños de 3 años a 4 años

Historial del Pasado Medico para Niños de 5 años a 8 años

Historial del Pasado Medico para Niños de 9 años a 11 años

Historial del Pasado Medico para Niños de 11 años a 17 años

Lista de Verificación para Contraindicación de Vacunas para Adultos

​Lista de Verificación para Contraindicación de Vacunas para Niños y Adolescentes

Dental 

Salud de Adultos / Historia Dental

Historial Dental y Médica de su Paciente

** Una copia de la tarjeta de inmunización también será necesaria para todos los adultos y niños.

Por favor, traiga todos los documentos de inmunización para cada visita con nosotros.

BCHF is a Federally Qualified Health Center and a Federal Tort Claims Act deemed organization. The Federal Government is the primary insurer.
Borrego Health receives HHS funding and has federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims for itself and covered individuals. 2020 Borrego Community Health Foundation (Borrego Health). All Rights Reserved.