Forms

Forms

COVID-19 Symptom screening

This form must be completed prior to any in-clinic appointments, on the day of the appointment. This must be completed for each visit to the health clinic.

Forms for Telehealth

All patients being seen for telehealth need to be within the state of Oregon at the time of the appointment, and need to complete the telehealth consent form prior to the appointment. This form needs to be completed once.

Sports and Program Physicals

Please email your completed physical form to lcchealthclinic@lanecc.edu prior to your telehealth visit. 

Forms for New Patients

All new patients need to complete the new patient paperwork before they can be seen by a provider through telehealth, a phone visit, or in-person in the clinic.

  1. New Patient Paperwork
  2. Medical History Form
  3. Please read Notice of Privacy Practices

If you have been seen by another provider and wish to follow up care at the health clinic please complete a release of records form prior to your appointment so we can give you the best care possible.

Please bring you medications with you to your appointment, or take photos of them with your phone. It is important that we have the name, dose and frequency of all medications that you take.

Oregon Health Plan Sign up Assistance

We are happy to help you sign up for the Oregon Health Plan (OHP). Call us to make an appointment to sign up for OHP Please fill out he Community Partner Assistance Consent and email the form to lcchealthclinic@lanecc.edu prior to your appointment.