Language
  • English (US)
  • Spanish (Latin America)

  • SBHC Appointment Request and Registration

    Para el español, haga clic en el botón de idioma en el lado derecho y seleccione español.
  • Who is completing this form?*
  • Patient/Student Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your preferred language?*
  • Have you already filled out a registration form for the School-Based Health Center?*
  • Where do you/the student want to receive care?*
  • What's your reason for needing a visit?
  • What is the best way to reach you?*

  • Registration Information

  • How do you want to complete your registration information?*
  • Is this also the address where you live?*

  • Health Insurance Information

  • Do you/does the student have health insurance?*
  • When did the health insurance start?*
     - -
  • Are you the insurance subscriber?*

  • Income and Demographics Questionnaire

    We are a community health center and are required to collect income information from all patients. This information helps us receive grant funding to provide you more services. All answers are confidential and are not shared with any other organization or program.

  • Estimated yearly household income in U.S. dollars (check the most accurate)*
  • Are any of the following true for you?*
  • Do you identify as Hispanic or Latino?*
  • Which one or more of the following would you say is your race?*

  • Sharing Your Visit with Your Primary Care Doctor

    One Community Health (OCH) will only release Protected Health Information (PHI) as permitted by patient confidentiality laws. OCH reserves the right to use or disclose patient’s PHI without patient’s consent to the extent allowed by applicable law,including but not limited to uses or disclosures identified in OCH’s Notice of Privacy Practices.
  • Format: (000) 000-0000.
  • Protected information to share: Certain information cannot be released without specific authorization as required by state or federal law. By checking the specific boxes below,you authorize the disclosure of the following protected information with your doctor:

  • Authorization

    • I understand that this authorization is valid as long as I am a patient of Hood River Valley High School Health Center, or I revoke my
      authorization.
    • I understand that I may revoke this authorization in writing at any time but that revocation of this authorization will not apply to
      information already released.
    • This form is not valid unless signed and dated.
  • Clear
  • Date
     - -

  • Please click the submit button to complete this form. If you entered your email address you will receive a confirmation email.

  • Should be Empty: