New Patient Forms

Download and fill out each form to bring to your first appointment. If you do not, please come to your appointment 20 minutes early to fill them out at the office.

1) Patient Health History. The Health History form for both adults and children is important to fill out completely for your provider so that they have a complete picture of your health.  There are separate forms for your medical health history and dental health history.

2) Consent for Treatment: White House Clinics requires all patients to complete documentation that verifies their consent to the treatment provided.

The Consent for Treatment Form (Adults / Pediatrics) does the following:

  • Gives White House Clinic providers permission to treat you
  • States that you agree to pay for services and allows White House Clinics to bill and collect payment from your insurance provider
  • Acknowledges that you have received a copy of our Privacy Notice

Patients who are 17 years and younger or adults with a guardian must also have minor consent form on file with us.  The Minor Consent Form tells our staff who the legal guardian is as well as who can bring the child to appointments.  If you anticipate ever needing a relative or neighbor to bring your child to an appointment you can use this form to indicate who you authorize to do this.  This form also tells us what school or daycare your child attends so that we can send paperwork like school excuses and shot records directly to the school or daycare – saving you a trip to our office.

3) The Patient Communication Form lets our office know how you would like for us to contact you in regard to your health information (appointment reminders, test results, referral information).  It also tells our staff if they can leave you a message or if there is anyone like a spouse, child, or friend that our staff can discuss your appointments, billing concerns, or other health information with when you are not available.

Sliding Fee Application 

As a Federally Qualified Community Health Center, White House Clinics receive federal funding to provide a discount to uninsured or indigent patients. The federal government provides specific instruction as to the use of this money so White House Clinics follow very standardized procedures for enrollment. Patients interested in enrolling in the discount program meet with the financial counselors at one of our locations, complete the Sliding Fee Application Form, and provide information regarding your household (number of people, income, etc.).

Requesting a Medical Record

White House Clinics now offers an online request tool below that verifies your identity by asking for a photo of your driver’s license, which can be taken via webcam or smartphone. There is no additional charge to use this service.

Please note, Chrome, Safari and Firefox are the recommended browsers for this application.

Click Here to Request Online

School Forms

Kentucky’s school health requirements

Kindergarten entry requirements:

  • A valid Kentucky Immunization Certificate. This can be requested by calling our office if your child had vaccinations completed in one our clinics.
  • A physical examination done within one year prior to entering school.
  • Eye examination done by ophthalmologist or optometrist by January 1 of the year of enrollment.
  • Proof of a dental screening  or examination by a dentist, dental hygienist, physician, registered nurse, advanced registered nurse practitioner, or physician assistant.

School-Based Mobile Oral Health Services

School-Based Mobile Dental Consent Form – Garrard County
School-Based Mobile Dental Consent Form – Madison County
School-Based Mobile Dental Consent Form – Berea Independent Schools

List of All Forms

Adult Health History (Ages 18 and older) (PDF)
Pediatric Health History (Ages 17 and younger) (PDF)
Dental Health History (All Ages) (PDF )
Adult Consent for Treatment Form (PDF)
Minor Consent Form (PDF)
Patient Communication Form (PDF)
Confidential Financial Statement (PDF)
Self-Declaration of Income (PDF)
Employer Income Attestation (PDF)
Request for Copy of Medical Records (PDF)
E-Communications Form (PDF)
School-Based Mobile Dental Consent Form – Garrard County (PDF)
School-Based Mobile Dental Consent Form – Madison County (PDF)
School-Based Mobile Dental Consent Form – Berea Independent Schools (PDF)

Spanish Forms

Adult Health History (PDF)
Pediatric Health History (PDF)
Dental Health History (PDF)
Consent for Treatment (PDF)
Patient Communication Form (PDF)
Release of Patient Records (PDF)
Sliding Fee Self Declaration (PDF)
Employer Income Attestation (PDF)