Release of Records Form

These forms allow your CHCNC clinician to access information from other individuals or agencies you currently receive or have received health care services from. This is an important step to managing your care because it ensures that our clinicians are fully aware of all of your health care needs and your health history. If you have any questions regarding these forms, please contact one of our sites listed on the bottom of this website's homepage.

Canton Site Form
Gouverneur Site Form
Franklin County Site Form
Jefferson County Site Form

Dental Sealant Program

Please fill out this form in its entirety and return the completed form to your child's school health office.

Program Enrollment Form

Patient Satisfaction Survey

Your experience at our health center is important to us. To help us assess the quality of care and services we are providing you, please fill out our patient satisfaction survey below.

This survey can be submitted to us a number of ways, you can:

Print the survey, fill it out by hand, and mail it to 4 Commerce Lane, Canton, NY 13617
Fill the form out online, save it, and e-mail it to
Fill the form out online, print it, and mail it to the above address or fax it to (315) 379-9521

Patient Satisfaction Survey Printable Form