AVITA 1008 Pharmacy

818-301-6378

Member Services

818-763-8836 x1053

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Patients

New Patient Forms

In preparation for your upcoming appointment, please download ALL these new patient forms or pick them up from the clinic.

You must complete and return ALL the forms to VCH by 12 noon on the business day (Mon-Fri) before your appointment, or your visit will be rescheduled to a later date.

Drop off your FIVE completed forms at the clinic, email them to [email protected], or fax them to 818-301-6354.

Registration Forms

General Consent Forms

Telehealth Consent Forms

Confidenial Health Questionnaire

Medical Record Request

Registration Form

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

English

Español

General Consent

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.

English

Español

Telehealth Consent

This form provides consent to receive telephone or video visits provided by VCH. Please print the form, fill it out, sign your name and bring to the clinic.

English

Español

Confidential Health Questionnaire

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.

English

Español

Medical Record Request

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

English

Español

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.

Patient Information

We empower patients to take responsibility for, and share in, decisions regarding their health status, forming a partnership between patient and healthcare provider.

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.

Clinical Services

We care for family members of all ages in the same facility, improving their health and wellbeing regardless of their ability to pay.