Patient Forms

Placeholder Image

As a convenience to you, we have posted several forms we commonly use in our practice.

Information transmitted via this site is protected by GeoTrust® Quick SSL. SSL encrypts data (credit card numbers and other personally identifiable information), which prevents anyone from stealing your information for malicious intent. An SSL protected page has an address that begins with https. We take the privacy of your health information seriously and have taken every precaution to protect it.


  • FAQNew Patient Form
    If you would like to join our practice, please click on the above link and fill out the form. If you are a member of a CHP employer group health plan with medical clinic benefits, please call us directly to become a patient.

  • FAQHealth History Form
    If you have already registered you can download the Health History Form. You can either print the form and fill it in by hand or you can fill it in on your computer.

  • FAQAuthorization to Disclose Protected Health Information
    If you would like to release your protected health information from Grand Valley Primary Care please fill out this form.


  • FAQGrand Valley Primary Care’s Lifestyle Medicine Program Questionnaire
    FAQGrand Valley Primary Care’s Lifestyle Medicine Program Intake Form
    If you have been referred to the Grand Valley Primary Care Lifestyle Medicine program, please print and complete the forms located in the above links. Completed forms must be returned to 603 28 1/4 Road prior to your appointment, so the provider has time to review them. Forms may also be faxed to 970-263-2690. If you have any issues or questions regarding these forms, please call us at 970-263-2600.