Patient Registration Forms

 

Medical Patients

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

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

 

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:

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 Agreement Informed consent for TeleMental Health (TMH) Treatment

 

Family PACT (Sexual/Reproductive Health) Patients

Students who are enrolling in the FAMILY PACT REPRODUCTIVE HEALTH PROGRAM have multiple options for submitting paperwork:

 

Options for completing forms

You are only required to complete ONE of the following options to submit your forms.

OPTION 1 - PRINT/SCAN: Print out and complete required paperwork, including signatures, then scan and send files back to studenthealth@ohlone.edu

OPTION 2 - PRINT/PHOTO: Print out and complete required paperwork, including signatures, then take a clear photo of ALL pages and email photos to studenthealth@ohlone.edu

OPTION 3 - FILLABLE PDF: Fill out paperwork electronically, including signatures. Save completed forms, and email to studenthealth@ohlone.edu

  • To electronically sign form, click the signature icon at the top of page (second icon from right). Select draw, and draw your signature. Drag the image of your signature into the signature box.
  • Be sure to save your electronically filled forms before sending.

If you require assistance or have questions about any of these forms, please call us at 510-659-6258 or email your questions to studenthealth@ohlone.edu

 

Family PACT Client Eligibility Form Please complete all highlighted areas on the first two pages, including a signature at the bottom of the second page.
Family PACT Female Medical History Form Please fill out a medical history form according to your gender. There is a required signature at the bottom of the second page.
Family PACT Male Medical History Form Please fill out a medical history form according to your gender. There is a required signature at the bottom of the second page.
Family PACT Superbill This form only requires a signature at the bottom of the third page
Family PACT patients MUST submit some form of photo ID to studenthealth@ohlone.edu. This can be a passport photo, school ID, California ID, or drivers license. A picture of your ID taken with your phone is acceptable.