Forms Health & Finance

Medical

• Non-Parental Consent for Minors ENGLISH
• Non-Parental Consent for Minors SPANISH
• New Patient Form ENGLISH/SPANISH
• Annual Wellness Visit Form Form ENGLISH/SPANISH

Dental

• Oral Health History Form ENGLISH
• Oral Health History Form SPANISH

School-Based Health Center

• Talbot County Enrollment English
• Talbot County Enrollment Spanish
• Caroline County Enrollment English
• Caroline County Enrollment Spanish
• Caroline County Enrollment Creole
• Talbot/Caroline Enrollment Staff
• Kent/Queen Anne’s Dental Enrollment English
• Kent Queen Anne’s Dental Enrollment Spanish
• Dorchester County Dental Enrollment English
• Dorchester County Dental Enrollment Spanish

Financial

• Sliding Fee Application ENGLISH
• Sliding Fee Application SPANISH
• Sliding Fee Application CREOLE
• Sliding Fee Application and Pt Agreement ENGLISH
• Sliding Fee Application and Pt Agreement SPANISH
• Sliding Fee Application and Pt Agreement CREOLE
• Pt Financial Responsibility Form ENGLISH
• Pt Financial Responsibility Form SPANISH
• Consents and Assignments ENGLISH
• Consents and Assignements SPANISH
• CCHS HIPAA Notice of Privacy Practices