Forms

These are the forms Central Montana Family Planning requires in order to establish and/or maintain your healthcare with our clinic.

Feel free to download, fill-in (when applicable), print-out, sign, and return to us at your appointment time.

Acrobat (free) or other PDF file reader is required in order to view the documents unless otherwise indicated.

FORMS MUST BE FILLED OUT IN EITHER BLUE OR BLACK INK ONLY.

~ Forms Required at First Visit, Annually, or Whenever Address and/or Income Changes ~

• Central Montana Family Planning Data Sheet version 02/2011 *renewed annually
• Medical Services & HIPAA Acknowledgment version 05/2010 *first visit or if legal name changes

~ Forms Required at First Visit Only ~

• Female Health History *not a fill-in form
• Male Health History *not a fill-in form

~ Forms Required if You've Had an Exam Within the Last 12 Months with Another Provider ~

• Medical Request or Release form

~ Forms Needed if Your Plan on Using Your Parental Income and/or Insurance ~

• Parental Insurance Consent

~ Forms Needed to Allow or Deny Parental/Guardian Information About Your Patient Status ~

• Patient Information Parental Release

~ Client Satisfaction Survey ~

Please fill out and either mail or drop off, survey is ANONYMOUS. Thank you!

• SURVEY

~ Birth Control Method Information & Consent Sheets* ~

Your method of choice will be discussed at length at your appointment. You'll be required to sign a consent for your preferred birth control method.
*Microsoft Word documents

• "The Shot" Depo Provera Hormonal Injection
• "The Ring" NuvaRing
• Oral Contraceptive Pills
• Oral Contraceptive Pills Continuous Cycling (period 3 times a year)
• Oral Contraceptive Pills Menses Cessation
• Oral Contraceptive Pills Progestin-Only "The Mini Pill"
• Plan B Emergency Contraceptive
• "The Patch" Transdermal Contraceptive