Forms

Patient Forms: English

Patient Registration Information

Patient Consent

Medical Information Release

Consent of Medical Treatment for Minors

Adult Past Medical History

Patient Portal Consent

Telemedicine Consent

Augmedix Consent

Cell Phone Policy

Medical Record Request From Another Facility

Medical Record Release To Another Facility

Immunization Registry Consent – Adult

Immunization Registry Consent – Minor

Formularios de Pacientes: Español

Informacion de Registro de Paciente

Consentimiento para el Tratamiento Medico

El Portal de Paciente

Consentimiento para Tratamiento Medico de Menores de Edad

Uso de Teléfonos Celulares y Dispositivos Móviles

Video Chat: Helpful Documents

How To Use Our Video Chat To See Your Physician

Troubleshooting Guide For Your Smartphone

Employment Application

Employment Application

All forms above are in Adobe PDF format, and require Acrobat Reader. If you do not have Acrobat Reader, you may download it for free by clicking below.

• Testimonials

  "Youens & Duchicela Clinic's staff is the reason I use them as my primary care giver. From the kindness they show to the knowledge they possess, its always a positive experience each time I go to the clinic for treatment."
  
  - James