Patient Forms
New Patients
Registration Form
Complete this form to be registered as a Unity Care NW patient.
Patient Rights and Responsibilities
Find out about your rights and responsibilities as a Unity Care NW patient.
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Download Russian Version
Download Spanish Version
Notice of Privacy Practices
Find out how your medical information may be used and disclosed. Unity Care NW respects your privacy, and we understand that your personal health information is very sensitive. We will not disclose your information without your approval or unless the law authorizes or requires us to do so.
Receiving Care
Dental Health History – Children
Complete this form to provide your child’s medical health history before receiving dental care.
Dental Health History – Adults
Complete this form to provide your medical health history before receiving dental care.
Consent to Dental Treatment
This form provides your consent to receive dental services.
Demographics Form – Adults
Patient demographic information helps us provide care and meet federal grant reporting requirements.
Demographics Form – Children
Patient demographic information about your child helps us provide care and meet federal grant reporting requirements.
Health History – Adults
Adults can use this form to provide us with information about their health history.
Download English Version
Health History – Children
This form is for the health history of patients under age 18.
Download English Version
Acknowledgements and Consent Form
This form authorizes consent to be examined and treated, as well providing a brief summary of your rights and responsibilities as a patient.
Release of Information
To request transfer of your medical record to another facility or to request a personal copy of your medical record, complete a Release of Information Form.
Children Under Age 18
Alternate Caretaker Authorization for Minor Patient
If you are a caretaker (other than a parent, guardian, or relative) of a minor patient, complete this form to authorize care.
Kinship Care Authorization for Minor Patient
Complete this form to authorize care for a minor patient if you are a relative or have a kinship responsibility.
Unaccompanied Minor Authorization
This for authorizes Unity Care NW to care for patients ages 13 and older without a parent or guardian.
Insurance and Sliding Fee Discount Program
Insurance Benefit and Payment Obligation Form
Learn about insurance and billing practices at Unity Care NW.
Sliding Fee Discount Program Application
To apply for the Sliding Fee Discount Program, complete the Application and provide proof of income.
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Download Spanish Version
Self-Attestation of No Income
If you are applying for to the Sliding Fee Discount Program and have no income, please complete this form.
Download English Version