New Patient Forms
As a new patient at Providence Everett Healthcare Clinic, you'll need to fill out a few forms for yourself and/or your child. Here you can print and fill out the forms ahead of time. Be sure to bring the completed forms with you to your first appointment.
New Patient Forms - Adults
Patient Information (PDF)
Comprehensive Patient History (PDF)
Mental Health Screen (PDF)
Notification of Clinic Policies (PDF)
Notice of Privacy Practices (PDF)
New Patient Forms - Children
Patient Information (PDF)
Pediatric Health History (PDF)
Permission to Treat Minor (PDF)
Notification of Clinic Policies (PDF)
Notice of Privacy Practices (PDF)
New Patient Forms - Mental Health
Adult Psychiatric Evaluation (PDF)
Child/Youth Psychiatric Evaluation (PDF)
ADHD Evaluation - Child (PDF)
ADHD Evaluation - Adult (PDF)