The Youth Clinic, Fort Collins, Colorado: New Patient Packets

New Patient Representative:
970-267-9717

New Patient Packets

As a new patient at the Youth Clinic, we have several forms that will need to be filled out prior to your visit. These forms range in content from providing us a brief family history to authorizing us to file your insurance. You can download the forms below and bring them to your first visit.

Important Note: Prior to receiving vaccines from the Youth Clinic, new patients are required to submit a copy of their immunizations records.

Newborn Packet

New Patient Packet

Forms Included in Above Packets:

Family Contact Information Sheet

Family Medical History

HIPAA Form

Medical Records Release

Patient Information Sheet

TB/Lead Questionnaire

Youth Clinic Financial Policy

Additional Forms:

Patient History Birth Through Five Years

Patient History Six Through Twelve Years

Patient History Thirteen Through Eighteen Years