Downloadable Forms

Dental

Medical

Adult Registration (.pdf)

Adult Registration (.pdf)

Adult Caries Risk Assessment (.pdf)

Children 5 and Older (.pdf)

Child Registration (.pdf)

Children Under 5(.pdf)

Child Caries Risk Assessment (.pdf)

 COVID 

Minor Consent Form (.pdf)

 COVID Infusion Referral Form

Notice of Privacy Practices (.pdf)

School Based Clinic Paperwork (.pdf)

Surveys

Farmington

Potosi

Great Mines Health Center provides comprehensive primary health, dental and mental health services to persons of all ages, income levels and insurance status, regardless of ability to pay.  The charges for services at a FQHC are discounted to patients according to a sliding fee scale, based on family size and income.

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