Downloadable Forms

All forms are in Adobe Acrobat Reader format.  Download form, fill out and return to Teller County Public Health.
If you don't have Adobe Acrobat, you can get a free copy here - Adobe Acrobat

 Clinic Forms

 New Client Women's Wellness Connection (WWC) Forms
    • WWC Registration Form
    • WWC Client Profile Tool
    • WWC Clinical Cycle Data Entry Tool
    • WWC Medical History Form
    • WWC Consent Form

New Client Family Planning Forms 
    • Family Planning Registration Form
    • Comprehensive Family Planning History – Female
    • Comprehensive Family Planning History – Male


 Immunization Forms

Immunizations - Ages 18 and Under
    • Client Registration Form
    • Immunizations- Child Registration Form
    • Immunizations- Child Questionnaire Form

 Immunizations - Ages 19 and Over
    • Client Registration Form
    • Immunizations- Adult Questionnaire Form

  Tuberculosis Screening (PPD)
    • TB Client Registration Form
    • TB Consent Form