patient forms

Providing Comprehensive Health Care for Everyone.


Want to become a patient? Call to make your first appointment or stop by one of our locations to pick up a new patient folder. It will contain several documents.

Please be sure to fill out the Patient Demographics form and Patient History as completely as possible. Arrive early to your first appointment, so our staff can review your paperwork.

We value and protect your privacy and confidentiality. As a patient, we encourage you to review our policies and notices.

Request to Transfer Records

Please fill out the following form and email, fax, mail or drop it off at LCHC. Questions? Please call 920-686-0453.

EMAIL or FAX TO 920-783-6805

AUTHORIZATION FOR DISCLOSURE Autorizacion de Divulgacion

*Once submitted, medical and dental records may take up to 30 days to transfer.

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