Patient Forms

The following forms are available for you to print and fill out before your scheduled appointment. If you need assistance, please contact your local clinic or email contact@mountainvalleys.org.

To Complete a Fillable PDF:

  • Click the PDF Link below

  • PDF will open in a new window

  • Click on first box and complete

  • Tab through each selection until complete

  • Click "Save As" to save your document

  • Print and bring to appointment OR email document to contact@mountainvalleys.org

Medicare Annual Wellness Visit

Health Risk Assessment

Self-Declaration of Income

English

Sliding Fee Application

English

Self-Declaration of Income

Spanish

Sliding Fee Application

Spanish

Forms may be submitted to 
contact@mountainvalleys.org