Patient Intake Forms

Please print the intake forms and fill them out prior to your appointment. Please bring the completed forms with you to your scheduled appointment.

New Patient

Patient's that have not visited Greene County Health should download and print out the appropriate intake paperwork using the links below. Please bring the completed forms to the office with you at your first appointment.

  • Adult New Patient Intake Forms
  • Pediatric New Patient Intake Forms
  • Demographics and HIPAA

    Demographics and HIPAA forms are to be completed on an annual basis. If it’s been longer than an year since you have updated your demographics or have any changes in your demographics, you may print and complete the below forms below to bring with at your next visit.

  • Established Patient Demographics and HIPAA Forms
  • Release of Information

    Authorization to Treat

    If you are unable to accompany your child to his/her medical visit, you may complete the below form and send with an authorized adult at the child’s next visit.

  • Parental Authorization to Treat Minor Child When Not Accompanied by Parent or Guardian