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

Please complete   * Required forms.

*

Membership Application

Membership Application

Fillable

Membership Application

 (older word ver)

Fillable

Membership Application

for Printing

If emailing forms/documents please use:

admin@niccdpc.com

‚Äč

If sending regular mail please use address:

Nicc's Direct Primary Care

4509 S. 6th Street, Suite 301

Klamath Falls OR  97603

*

Retainer Medical Agreement

Retainer Medical Agreement

*

Medical History

Medical History form

Fillable

Medical History form

for Printing

*

Consent / HIPAA

Patient Consent / HIPAA

Release of Records