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  • Community Health Center of the North Country | Canton
  • Phone: (315) 386-8191
  • Fax: (315) 386-1410
  • Community Health Center of North Country | Malone
  • Phone: (518) 483-0109
  • Fax: (518) 483-0115
  • Community Health Center of North Country | Watertown
  • Phone: (315) 786-0983
  • Fax: (315) 786-0994
  • Community Health Center of the North Country | Gouverneur
  • Phone: (315) 287-4440
  • Fax: (315) 287-1858
  • Community Health Center of the North Country | Ogdensburg
  • Phone: (315) 713-9350
  • Fax: (315) 713-9351

MINOR NEW PATIENT PACKET

Welcome to Our Practice
Services Available by Location
Sliding Fee Scale
HIPAA Notice of Privacy
FQHC Survey *
Health History Form *
Consent to Discuss & Accompany *
Consent for Treatment *
HIXNY Consent Form *
HealthEConnections Consent Form *
Telehealth Consent Form *

Forms marked with a * are required to be filled out prior to your visit.

Bienvenida a nuestra practica
Servicios disponibles por ubicación
Escala de tarifas
Aviso de privacidad de HIPAA
Encuesta FQHC *
Formulario de historial médico pediátrico *
Consentimiento para discutir y acompañar *
Consentimiento para el tratamiento *
Formulario de consentimiento de HIXNY *
Formulario de consentimiento de HealthEConnections *
Formulario de consentimiento de telesalud *


Los formularios marcados con un * deben completarse antes de su visita.

  • Copyright © 2023 Community Health Center of the North Country | Canton, all rights reserved.
  • 4 Commerce Lane,  Canton, NY 13617   (315) 386-8191