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Patient Forms

We know health care visits can feel overwhelming. That’s why we work to simplify every step, so you get the most out of your time with your provider.

Make an Appointment

Become a Patient

Below are forms that you can print and complete before your first appointment to help make the registration process faster when you arrive, or we’ll give you blank copies of these forms to fill out in the waiting room. We look forward to seeing you!

Team member at Coastal Health Alliance dental clinic standing at the front desk, smiling and wearing pink scrubs beneath the Coastal Health Alliance sign.

New Patient Letter

Our new patient letter welcomes you and shares information about Petaluma Health Center.

Medical provider at Petaluma Health Center talking with a patient in an exam room, smiling while taking notes on a clipboard.

Registration Form

All patients must print, fill out and bring along to your appointment.

Petaluma Health Center call center staff member wearing a headset and smiling while assisting a patient over the phone at her workstation.

Transfer Medical Records

This will allow us to release your medical records to other providers and facilities.

Current Patients

Petaluma Health Center’s team is here to help you along every step of your health journey. If you need assistance or want to be connected with support services, please call us.

Request Medical Records

Please request a copy of your medical records online at https://scanstat.com/patient-record-request/

Authorize Text Messages

Authorizing text messaging allows PHC to remind you of an appointment, obtain feedback on your experience with our healthcare team, and provide general health reminders/information.

Insurance & Costs

Sliding Fee Scale Eligibility

If you don’t have insurance, you may qualify for financial assistance based on your income level. The document below outlines eligibility criteria and service rates by income and family size.

Sliding Fee Scale Enrollment

Patients without insurance who are requesting discounted services are required to complete a Sliding Scale Application. Please print the form below, fill out and bring along to your appointment.

Health Insurance Enrollment

If you need to sign up for health insurance, the document below contains a checklist that will help you prepare for your meeting with a Certified Enrollment Counselor.

Patient Rights, Privacy & Appointment Policies

Rights & Responsibilities

Please take a moment to review your rights and responsibilities as a patient. Understanding these helps ensure that you receive the best possible care and that we can maintain a safe, respectful, and efficient environment for all patients and staff.

Your Privacy

Please review our Medical Information Privacy Policy below, which describes how medical information about you may be used and disclosed and how you can get access to this information.

Cancellations & Late Appointment Arrival

Please call (707) 559-7500 if you need to cancel or if you’re running late.

We ask for at least 24-hour notice for cancellations. If you’re delayed, we’ll do our best to accommodate you; however, in some cases, we may need to reschedule your appointment.