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).
- Medicare Wellness Packet
- New Patient Packet – Kids Under 12
- New Patient Packet – Kids Under 12 (Spanish)
- New Patient Packet – Adolescents Teens 12-17
- New Patient Packet – Adolescents Teens 12-17 (Spanish)
- New Patient Packet – Adults
- New Patient Packet – Adults (Spanish)
- New Patient Packet – 65+ Adults
- New Patient Packet – 65+ Adults (Spanish)
- New Patient Packet – Medicare
- New Patient Packet – Medicare (Spanish)
- Release of Records Authorization Form
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 2 months (Spanish)
- ASQ 4 months
- ASQ 4 months (Spanish)
- ASQ 6 months
- ASQ 6 months (Spanish)
- ASQ 9 months
- ASQ 9 months (Spanish)
- ASQ 12 months
- ASQ 12 months (Spanish)
- ASQ 16 months
- ASQ 16 months (Spanish)
- ASQ 18 months
- ASQ 18 months (Spanish)
- ASQ 2 years
- ASQ 2 years (Spanish)
- ASQ 3 years
- ASQ 3 years (Spanish)
- ASQ 4 years
- ASQ 4 years (Spanish)
- ASQ 5 years
- ASQ 5 years (Spanish)
- M-Chat 18-24 months
- M-Chat 18-24 months (Spanish)
- Top 5 Questions for Your Diabetes Team
- Top 5 Questions for Your Diabetes Team (Spanish)
- Depression (Spanish)
- Stress (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.