Membership Forms

All forms below are **Required** for membership

Membership Application 

Applications are the same just different formats. Only need to select one that is compatible with your device needs.

Older Word Doc

Retainer Medical Agreement 

Medical History

There are two versions of this form.  The word document is a tab or mouse fillable form and may be emailed to admin@niccdpc.com or completed and printed.

Medical History Form For Printing

Medical History Form Fillable

Consent / HIPPA 

Parent Constent HIPPA

Release Of Records

Upon Completion Of ALL Medical Documents...

You can bring them into the office on your next appointment or email them to our office at

Office Phone:  541-238-6432     4509 S 6th Street, Suite 301, Klamath Falls OR  97603