Appointments

(818)-763-8836

Member Services

818-301-6399

Patients

Patient Forms

Registration Forms
Registration Form – RA1 (English)
Registration Form – RA2 (Spanish)

Note: These forms are for new patients to complete. Please print the form, fill it out, sign your name and bring to your clinic appointment.

Medical Record Forms

Medical Record Form – MR1 (English)
Medical Record Form – MR2 (Spanish)

Note: Complete this form to ask for your medical records. Please print the form, fill it out, sign your name and bring to the clinic.

Confidential Health Questionnaire Forms

Adult Forms

Confidential Health Questionnaire Form – CHA1 (English)
Confidential Health Questionnaire Form – CHA2 (Spanish)

Senior Forms

Confidential Health Questionnaire Form – CHS1 (English)
Confidential Health Questionnaire Form – CHS2 (Spanish)

Note: Complete this form to give us more details about your health. Please print the form, fill it out, sign your name and bring to the clinic.

Patient Consent Forms

Patient Consent Form – PC1 (English)
Patient Consent Form – PC2 (Spanish)

Note: This form provides consent to the treatment and services provided by VCH. Please print the form, fill it out, sign your name and bring to the clinic.

Health Risk Assessment Forms

Health Risk Assessment Form – HRA1 (English)
Health Risk Assessment Form – HRA2 (Spanish)

Note: Complete this form to give us more details about your health. Please print the form, fill it out, sign your name and bring to the clinic.

High-Quality Healthcare for All

The mission of Valley Community Healthcare is to improve the health and wellbeing of our community by providing high-quality comprehensive healthcare services regardless of ability to pay.

Welcome to Your Medical Home

Valley Community Healthcare doctors work together with health specialists to treat all the issues that affect a patient’s physical condition and mental well-being, including diet, exercise, and substance misuse.

Make a Difference with VCH

Your gift to Valley Community Healthcare ensures that we can create little miracles every day, so our patients won’t need big miracles to stay alive and well.