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Kīpuka O Ke Ola

Native Hawaiian Rural Health Clinic

Downloadable Forms

Welcome to our Intake Forms Page! Here, you can easily access and download all the essential forms required for your clinic visit. Streamline your check-in process by filling out these forms in advance, ensuring a smooth and efficient experience during your appointment. Download the necessary documents conveniently from this page and arrive prepared for your visit to our clinic.

Intake Forms for primary care clients

1 - Adult Patient-Clinic Agreement Form (Rev 1/2/24)

2 - Adult Primary Care Forms

3 - Pediatric Primary Care Forms

4 - Womenʻs Health Forms

5 - Newborn Visit Questionnaire

Intake Forms for Behavioral Health clients

6 - Adolescent Behavioral Health Forms

7 - Psychiatry Forms (Rev 9/18/23)

8 - Adult Behavioral Health Forms

9 -TMS Intake Form

Miscellaneous Forms

10 - Consent to Release Information Form

11 - Sliding Fee Discount Program Application

12 - Sliding Fee Discount Program Policy/Procedure

13 - Application for Reinstating KOKO Services

14 - Volunteer Agreement and Code of Conduct Form

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