Downloadable forms

All of the forms on this page can be completed prior to your scheduled appointment. You may complete and print out at home or complete and email to us at  If you are unable to print or email the appropriate forms before your visit, please plan on arriving at least 15 minutes before your appointment time.

To use the fillable feature of these forms (i.e. input typed text), you will need to download a free version of Adobe Reader. For Windows operating systems, download here. For Mac OS X, download here

Registration Form

Please fill out to the best of your ability. All information is confidential.

Both the Registration Form and Patient Health History must be completed once each calendar year for all patients seen at Dahl Memorial Clinic.

Sliding Fee Scale Application

This form must be completed to apply for reduced charges under DMC's Sliding Fee Program.

Self Declaration Form

If you are requesting consideration for the sliding fee scale and are unable to provide documentation of your income, please use this form.

Consent to Treat Minor Children

Use this form to designate an individual to make care decisions for your child while you are away.

Medical Records Release

Use this form to authorize the transfer of your medical records from one facility to another.

PHQ-9 Adult Form

The PHQ-9 is an assessment tool for measuring the severity of depression.  Use this form if you are 18 or older.

PHQ-9 Adolescent Form

The PHQ-9 is an assessment tool for measuring the severity of depression.  Use this form if you are 17 or younger.


The Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to
identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related
health consequences, disease, accidents and injuries.

Hamilton Anxiety Form

The Hamilton Anxiety Rating Scale is an assessment tool for measuring the severity of anxiety.

E.A. & Jenny Rasmuson Community Health Center Donor Wall

While construction of the clinic is now complete, contributions continue to help us purchase equipment and improve services. Patrons of the clinic will have a metal plaque with their names engraved on it and displayed on a special donor wall at the clinic's entrance. To learn more about our Fishwall, and to see it in action, click here.

Fran DeLisle Cancer Fund Assistance Application