Please click the link above to download the form If you prefer to print the form and fill it out. You may bring it to your first appointment or submit it via the contact information below:
1890 Waite St.
North Bend OR, 97459
Patient Registration Form
Please fill out the form below to send us your registration information. Fields marked with an asterisk (*) are required.
Waterfall Community Health Center is a Federally Qualified Health Center and receives federal funding pursuant to Section 330 of the Public Health Service Act. We are required to collect information about age, gender, race, sexual orientation, income, and family size for statistical purposes only. No individual information is submitted.