Patient Forms

For your convenience, we are giving you the option to download, print and fill out the registration forms before you come in. If you prefer to do this at your time of appointment, please arrive a few minutes early to complete the registration forms so that we have all the necessary information to treat your child.

Pediatric Registration packets

• UBCP Pediatric Registration Packet 0-11 yrs old
• UBCP Pediatric Registration Packet 12-17 yrs old

Patient Registration Form

• Pediatric Registration Form
  
• Registro Para Pacientes de Pediatría- Español
  
• 儿童患者登记表 - Chinese

Consent

• Consent to Treatment of Minor
  
• Consentimiento Para el Tratamiento de Menores - Español

Terms & Conditions

• Terms & Conditions
  
• Términos y Condiciones de Registro, Servicios Médicos y Acuerdo Financiero - Español

Privacy Practices

• Notice of Privacy Practices Acknowledgement
  
• Recibo de Reconocimiento Del Aviso De Privacidad - Español
  
• Notice of Privacy Practices
  
• Aviso de Prácticas de Privacidad - Español
  
• 隱私權實施條例通知 加州大學三藩市分校UCSF 健康體系 - Chinese

My Chart Account

• UBCP MyChart Proxy Authorization Patient's Age 0 - 11 Yrs. Old

• UBCP MyChart Proxy Authorization Granting Proxy Access to Parent/Guardian on behalf of an Adolescent (Age 12 - 17 years)

Authorization for Release of Health Information

• Authorization for Release of Health Information
• Authorization for Release of Health Information - Español

M Chat

• MChat 
• MChat- Español
• MChat - Chinese
• MChat - Vietnamese

Additional Forms

Patient Health Questionnaire

Aces aware screening tool