Patient Registration Forms

Handing in Forms

Medical Patients

If you are a new patient to the Ohlone College Student Health Center seeking MEDICAL CARE, please complete the following forms:

Form Description
Patient Information Form Personal contact information and emergency contact
Medical History Questionnaire Medical history and preferred pharmacy
Financial Policy and Privacy Practices

Washington Township Medical Foundation Financial Policy 

Washington Hospital Healthcare System Notice of Privacy Practices

Patient Health Questionnaire (PHQ-9) A brief health questionnaire assessing your state over the last two weeks
TeleMedicine Informed Consent Informed consent for TeleMedicine visit

 

Personal Counseling (Mental Health) Patients

For clients at the Ohlone Student Health Center seeking PERSONAL COUNSELING, for the first time this semester, please complete the following forms:

Form Description
Confidential Initial Contact Form Contact Form About your background 

Patient Health Questionnaire (PHQ-9)

A brief health questionnaire assessing your state over the last two weeks
Telehealth & Informed Conesent Informed consent for TeleMental Health (TMH) Treatment