Patient Forms | Teche Action Clinic

Please review, print and fill out the following forms.

Follow the instructions on the document for return or return to a Teche Action Clinic.

Lack of Income Declaration
Patient Complaint
Patient Complaint Process, Rev 3.26.2021_spanish
Personal Representative Designation Form
Summary of Privacy Notice
Acceptable Proof of Income
Patient Information Brochure (English)
Folleto de Información del Paciente (Español)
Consent for Treatment and Authorizations (English)
Consentimiento para Tratamiento y Autorizaciones (Español)
Spanish Absent Parent Consent for Treatment Form
Spanish Personal Representative Designation Form
Acceptable Proof Of Income _kw_spanish
Advance Directives Brochure, Rev 2018_spanish
Lack Of Income Declaration Form
Patient Profile Forms
Spanish Lack of Income Declarations
Spanish Patient Profile Form
Absent Parent Consent For Treatment Form

Contact Us Today

At Teche Action Clinic, we are fully committed to providing our patients with personalized, caring service. If you have any questions or need any assistance, please Contact Us.

Please review, print and fill out the following forms.

Follow the instructions on the document for return or return to a Teche Action Clinic.

Contact Us Today

Resources

Main Menu

News

Get in Touch

Standard of Quality and Excellence

Resources

Connect with us!