Patient Forms

To prepare for your visit, please complete the required patient forms before your appointment.

  1. Select the appropriate form
  2. Download the form to your device or print a copy
  3. Complete all required fields
  4. Return to CHDC

Once your forms are completed or if you need help completing them, please contact our Pre-Registration staff by calling 610-326-9460 ext. 565.

New Patient Forms

Required for all patients:

Required for all new medical patients:

Required for all new dental patients:

Required for all patients; annually:

HIPAA Permissions

Only required if you want to transfer records in to CHDC:

  • HIPAA Release of Health Information (Transfer In) - English | Spanish

Only required if you want to transfer records out of CHDC:

  • HIPAA Release of Health Information (Transfer Out) - English | Spanish

Only required if you want to receive a copy of your personal health records:

HIPAA Privacy Notice and Communications Preference Forms are required to be updated yearly or when there is a change of information:

  • Consent for Treatment & Communication Preferences (New Form) - English | Spanish

Health Information Privacy Notice Brochure:

  • Patient Notice of Privacy Practices - English

Affordable Healthcare

Healthcare discount information & FAQ:

See how much of a healthcare discount you can get - effective 02/01/2026:

Apply for your Healthcare Discount:

Figure out what discount you get:

Healthcare provider assisting a patient with a form

CHDC Billing Text To Pay:

  • Payment reminder texts began on 1/8/2024
  • Reminder text will be sent out BEFORE billing statement
  • Texts are coming from (888) 695-7386
  • Link to pay included with the text