Ghost Pumpkin Moon
Patient Registration Forms
Form logo Our Patient Registration Forms packet is now available electronically for your convenience.

The registration packet includes:
  • Registration Form
  • Privacy Notice Acknowledgement
  • Patient Consent Form
  • Personal Medical History Form
Our registration forms are available in both English and Spanish.
Notice
PDF icon Adobe Reader or a similar PDF viewing application is required to view our forms.
Need Help?
Survey icon If you require assistance or have questions regarding these forms, please contact one of our health centers.
Advance Directive
What is an advance directive and why is it important?

An advance directive informs physicians and other medical providers about a patient's treatment preferences in the event of a critical illness. The advance directive is activated when a patient is deemed by a physician to be terminally ill or to have an irreversible illness/condition.

An advance directive:

  • Can be modified by the patient at any time
  • Cannot be overriden by anyone except the patient in sound mind

Advance directives can help to decrease suffering, increase quality of life and improve comfort at the end of life. Specific directives could include use of CPR or other resuscitation methods; life-sustaining equipment (dialysis/ventilator); artificial nutrition/hydration; and palliative care.

We at Samuel Dixon Family Health Centers, Inc., urge you to have an advance directive. Inform your family of your desires and keep your card (downloadable below) with you in the event of an emergency.

Advance Directive cards are available in both English and Spanish.