Well-being & Health Promotion Forms

Note: Some documents are in PDF format, unless otherwise noted (download Adobe Acrobat Reader, if needed).

Forms

• Family PACT Program Client Eligibility Certification (PDF)
  Family PACT provides free family planning services for women and men. Find out if you're eligible by completing this quick and easy application.

• Notice of Privacy Practices - California Department of Health Services (PDF)
  When it comes to your health information, you have certain rights. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

• Nutrition Intake Form
  Have an appointment with our Registered Dietician? Please have this form filled out and ready to go prior to your visit.