All forms are available at the front desk when you check in, and Spanish versions will be posted soon.
Consent, Privacy Policies, and Release of Records
State and Federal laws (including, but not limited to, HIPAA) require that Columbia Gorge Family Medicine keep your medical information confidential and secure. The Notice of Privacy Practices below describes how medical information about you may be used and disclosed as part of your ongoing care, and how you can get access to this information.
Patients are asked to provide (and periodically update) a detailed medical history, health screen, and consent forms when under the care of Columbia Gorge Family Medicine. Patients may be asked to print and fill out the some of the forms below before coming in for your visit (Spanish versions coming soon).
- FD1 Financial Policy Agreement
- FD2 Patient Demographics Form
- FD3 Adult Health Screening Form
- FD3 Adult Health Screening Form (Spanish)
- FW New Patient 65 Years and Over
- FW New Patient 65 Years and Over (Spanish)
- FD4 Adult Health Questionnaire (Review of Systems)
- FD5 Adolescent/Teen Health Screening and Questionnaire (Review of Systems)
- FD6 Consent for Treatment
- FD6 Consent for Treatment (Spanish)
- FD7 Release of Records Authorization Form
- Medicare Wellness Packet
Pediatric Developmental Screening (ASQ) Forms:
Before you bring your child in for a well check, we ask that you download and complete the appropriate Developmental Screening form for your child based on age, below.
- ASQ 2 months
- ASQ 4 months
- ASQ 6 months
- ASQ 9 months
- ASQ 12 months
- ASQ 16 months
- ASQ 18 months
- M-Chat 18-24 months
- ASQ 24 months to 2 years
- ASQ 36 months to 3 years
- ASQ 48 months to 4 years
- ASQ 60 months to 5 years
Pediatric Developmental Screening (ASQ) Forms (Spanish):
- ASQ 2 months (Spanish)
- ASQ 4 months (Spanish)
- ASQ 6 months (Spanish)
- ASQ 9 months (Spanish)
- ASQ 12 months (Spanish)
- ASQ 16 months (Spanish)
- ASQ 18 months (Spanish)
- M-Chat 18-24 months (Spanish)
- ASQ 24 months to 2 years (Spanish)
- ASQ 36 months to 3 years (Spanish)
- ASQ 48 months to 4 years (Spanish)
- ASQ 60 months to 5 years (Spanish)
Immunization Exemption Form:
By far, most parents in Oregon vaccinate their children. But parents who do not want their children to be vaccinated can claim a non-medical exemption for one or all school immunizations.
To claim this exemption through Columbia Gorge Family Medicine, you are required to watch an online education module and print a Vaccine Education Certificate at the link below. Note that the process for college students is a little different than the process for parents.
The link above will take you to Oregon’s Public Health Web site where you can watch the online education module and print your Vaccine Education Certificate.