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 |
A brief health questionnaire assessing your state over the last two weeks | |
Telehealth & Informed Conesent | 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. |