Valley Health Clinic, Inc
Valley Health Clinic, Inc

Patient Forms

Want to save time during your visit with us?  Please print and fill out the following forms and bring them with you on your first appointment.  This saves valuable minutes of your time.  If you have any questions please feel free to call us ahead of your appointment.

Don't forget to bring your insurance information with you

In order to register and treat you promptly, we request that our patients bring their current insurance information with them for each visit including picture identification. We also ask if you are currently taking perscribed medications to please bring them with you.

We accept most types of health insurance. Please contact us for further details.

Patient Registration Form
E registration form page 1.pdf
Adobe Acrobat document [70.4 KB]
Formulario de Registro del Paciente
SPANISH REGISTRATION FORM 2015.pdf
Adobe Acrobat document [115.2 KB]
Health History Questionnaire
Health_History_Questionnaire.docx
Microsoft Word document [372.2 KB]
School Physical Form
School_Physical_Form.pdf
Adobe Acrobat document [165.5 KB]
I-693 Immigration Form
Please only print and fill out the first page. The first page serves as a reference when filling out the form that will be sent to USCIS
i-693.pdf
Adobe Acrobat document [1.5 MB]
DOT Physical Form
DOT_Physical_Form.pdf
Adobe Acrobat document [120.2 KB]
N-648 Immigration Disability Waiver Form
n-648.pdf
Adobe Acrobat document [114.5 KB]

Eye Exam Forms 

Before your appointment for EYE EXAM ONLY
Please use this for the eye exams.
Before your appointment.pdf
Adobe Acrobat document [127.1 KB]
Patient Registration Form for EYE EXAM ONLY
Please use this for the eye exams.
E Registration Form.pdf
Adobe Acrobat document [72.1 KB]
Health History Questionnaire for EYE EXAM ONLY
Please use this for the eye exams.
Health History Questionnaire.pdf
Adobe Acrobat document [175.8 KB]
Informed Consent Dilation and Refraction for EYE EXAM ONLY
Please use this for the eye exams.
Informed Consent Dilated Eye Exam and Re[...]
Adobe Acrobat document [120.3 KB]
Contact Lens Policy for EYE EXAM ONLY
Please use this for the eye exams.
Contact Lens Policy.pdf
Adobe Acrobat document [148.6 KB]
Contact Lens Care and Use Guide for EYE EXAM ONLY
Please use this for the eye exams.
Contact Lens Care and Use Guide.pdf
Adobe Acrobat document [201.9 KB]
Print Print | Sitemap Recommend this page Recommend this page
© Valley Health Clinic 2018 - Web design by T. Sadler