What is Asthma? Smile, California 6. Vaping E-cigarettes and Youth 8. Vaping: Flavors Hook Kids Toolkit 9. Font Size A A A. Specialty Providers Specialty Providers. Register to Vote. Public Health has made reasonable efforts to provide accurate translation.
However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version. Dental Providers. Vision Providers. Specialty Providers. Contact Information. CHDP Forms. CCS Referral Process.
Specialty Referral, Guidelines and Tips. Newborn Hearing Screening Program English. Newborn Hearing Screening Program Spanish. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
The official entity for keeping the information is the Department of Health Services. MS Box , Sacramento, CA A copy of this information may be shared with the county Department of Social Services in the county in which you reside and will be kept with your child's medical record by your Child's CHDP provider.
Your information will be encrypted. Toggle navigation. Please correct the errors described below. Instruction to the Parent or Patient In order to receive a health examination today at no charge, you must provide the information required on this form. Is this patient less than 19 years of age? Yes No. How much money does your family make before taxes? Patient Information. If yes, what is the identification number on the BIC card if available?
Patient Name:. First Name:. Middle Initial:. Date of Birth:. Gender: Male Female. If you are homeless, check here. Enter the general location in the "Home Address" section and complete the "Mailing Address" section. Home Address:. Apartment :. Country of Residence:. Zip Code:. Mailing Address: if different from home address.
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