Patient Forms

Use the links below to submit refill request, dental request or patient intake form online. An intake form must be complete prior to TeleHealth appointments. Please submit refill requests 7 days prior to end of medications.

Patient Intake Form

Fill out this form prior to your first appointment. We provide care on Mondays and Wednesdays from 10 am to 4 pm and on Thursdays from 5 to 8 pm.

Patient Intake Form

Medication Refill Request Form

Please submit refill requests 7 days prior to the end of medications.

Medication Refill Form

Income Verification Form

Please verify your income.

Income Verification Form

Dental Care Request Form

Fill this form out prior to your first dental visit to request services.

Dental Care Request Form

findhelpidaho.org

findhelpidaho.org connects Idahoans seeking help with resources in their local community. It's free, confidential, easy to use, and provides up-to-date information in more than 100 languages. Through community collaboration and support, findhelpidaho.org works to improve health and social outcomes throughout Idaho.

Learn More