Patient Forms

Registration Forms

Patient Registration & Consent Form – English | Spanish | Russian
Authorization to Treat a Minor – English | Spanish | Russian
Designating a Personal Representative – English | Spanish | Russian
Release of Information Authorization – English | Spanish | Russian
Notice of Privacy Practice – English | Spanish | Russian

Sliding Fee Scale

Sliding Fee Scale Attestation – English | Spanish | Russian
Sliding Fee Scale Application – English | Spanish | Russian

Keep in Touch

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My OLE Health allows patients (18 years and older) to have better communication with their health center by allowing access from anywhere with an internet connection.

Patient Portal

Log in to My OLE Health Patient Portal here
Detailed instructions for activating your Patient Portal account
Instructions for Connecting your OMRON Blood Pressure monitor to your Patient portal English – Spanish

Tele-Video / Virtual Visit Checklist: English – Spanish

Secure Video Conferencing Instructions – Zoom Only

Instructions for Android Phones: English – Spanish
Instructions for Apple/IOS Phones: English – Spanish

Patient Forms

CHDP Pre-Enrollment Form
Access to Health Programs Form – English | Spanish
Pregnancy Test Flyer – English | Spanish
Personal Representative Designation Form / Formulario para Designar a un Representante Personal

Consent Forms for Caregivers

Caregiver’s Authorization Affidavit – English | Spanish
Consent to Treat a Minor – English | Spanish

Dental Forms

Dental Medical History – English | Spanish
Dental Policies & Procedures – English | Spanish
Dental DMFS Acknowledgment – English | Spanish
Dental Consent Treatment – English | Spanish

Behavioral Health Forms

Consent for Treatment – Long Term – English | Spanish
Consent for Treatment – Short Term – English | Spanish
Patient Portal Questionnaire Instructions – English | Spanish
Napa County Behavioral Resources – English | Spanish
Solano County Behavioral Resources – English | Spanish

Staying Healthy Assessment Forms

0-6 Months Old – English | Spanish
1-2 Years Old – English | Spanish
3-4 Years Old – English | Spanish
5-8 Years Old – English | Spanish
9-11 Years Old – English | Spanish
12-17 Years Old – English | Spanish
Adult – English | Spanish
Senior – English | Spanish