[!] Alert:

Our Pellston Clinic will be closed on Friday, February 26, 2021. Pellston staff will be temporarily relocated to Community Health Center of Northern MI (Harbor Springs). Calls to the Pellston Clinic will be forwarded to the Harbor Springs location.

Forms

New Patient Forms – Please print, fill out and return by mail (or drop off) to the location that you will be using.

Alcona Health Center’s Registration form and Financial Policies

Medical Records Release

ADULT Health History Form

PEDIATRIC Health History Form

School Based Location Forms – Please print, fill out and return by mail (or drop off) to the location.

Tiger Health Extension Consent Form

 

Sliding Fee Application – Please print, fill out and return by mail (or drop off) to the location that you will be using. 

Sliding Fee Supporting Documents

Download Sliding Fee Application 2020

Download Sliding Fee For Self-Employed Application 2020 Only use this long version of the form if you or someone in your household is self-employed.