Teller County Public Health

11115 W. Hwy 24, Unit 2C - behind Venture Foods
PO Box 928  -  Divide, CO 80814
Phone: 719.687.6416    Fax 719.687.6501

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 ReaderAdobe 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

Our clinic is a safe and completely confidential environment. All services at the clinic are offered on a sliding fee scale based on your income and are usually either low-cost or free. We also accept Medicaid.