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 Profile (English)
Perfil del Paciente (Español)
Personal Representative Designation Form
Summary of Privacy Notice
Acceptable Proof of Income
Patient Information Brochure
Consent for Treatment and Authorizations (English)
Consentimiento para Tratamiento y Autorizaciones (Español)

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

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