Patient Forms
Here you can find forms you may need for your care at Virginia Garcia. You can download and print these forms at home.
If you need any help with these forms, reach out to your care team. We’re here to help you every step of the way.
Patient Forms for Your Visit
If you need any help with these forms, reach out to your care team. We’re here to help you every step of the way.
Forms to Become a Patient
Annual Verification Form
English
Formulario de verificación anual
Spanish
MyChart Proxy Forms
Proxy Request Form
English
Formulario de autorización para el acceso del apoderado
Spanish
Dental Care Forms
Annual Verification Form
English
Formulario de verificación anual
Spanish
Income Verification & Discount Eligibility Form
English & Spanish
Adult New Patient Packet
English
nuevo paquete para pacientes
Spanish
Child New Patient Packet
English
Paquete para pacientes infantiles nuevos
Spanish
School-Based Health Center Forms
Annual Verification Form
English
Annual Verification Form
Spanish
Wellness Check-In
Grades 6-8
Wellness Check-In
Grades 9-12
Registro de Bienestar Personal
Grados 6-8
Registro de Bienestar Personal
Grados 9-12
Reproductive Health Forms
Enrollment Form
English
Enrollment Form
Spanish
Enrollment Form
Russian
Enrollment Form
Simplified Chinese
Enrollment Form
Somali
Enrollment Form
Vietnamese
Enrollment Form
Marshallese
Enrollment Form
Korean
Sliding Scale Program
Income Verification & Discount Eligibility
English & Spanish
Release of Information Forms
HIPAA Release of Information (ROI)
English
HIPAA Release of Information (ROI)
Spanish
Release of Verbal Health Information
English
Release of Verbal Health Information
Spanish