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 firstname.lastname@example.org. 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.
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.
This form must be completed to apply for reduced charges under DMC's Sliding Fee Program.
Use this form to designate an individual to make care decisions for your child while you are away.
Use this form to authorize the transfer of your medical records from one facility to another.
The PHQ-9 is an assessment tool for measuring the severity of depression. Use this form if you are 18 or older.
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.
The Hamilton Anxiety Rating Scale is an assessment tool for measuring the severity of anxiety.
Patients must only complete section 1. The remainder will be completed by the Medical Examiner during the examination. Please read the driver qualifications carefully prior to your appointment. DOT Physicals are an hour appointment. Please have your form completed when you arrive or allow 30 minutes to complete the form prior to your appointment time.
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.