For Your Convenience

Forms & Documents  

• Advance Directive (PDF in English/Spanish)
• Guild Volunteer Application
• Patient and Family Advisory Council Application
• Dr. Marengo's New Patient Breast Health Questionnaire
• Physician Orders for Life-Sustaining Treatment (POLST) (This will take you to the POLST site where you can download forms in multiple languages)

Occupational Health Forms    

• Treatment Authorization
• Drug Screen & Physical Authorization
• Consent for Drug Screen of a Minor
• Flu Vaccination Voucher

Financial Counseling

• Financial Assistance Program Policy
• Financial Assistance Program Plain Language Summary
• Financial Assistance Application Form
• Uninsured Discount Program

Primary Care

• Consent for Treatment & Financial Agreement
  • English
  • Spanish
• Treatment & Financial Agreement Acknowledgment
  • English
  • Spanish
• Medical History Form
  • English
  • Spanish
• No Show/Late Arrival Form