EN ES MyCareOnline DONATE About Us Leadership Strategic Plan Mission Our Donors Contact Us Careers Support Us Locations Services Costs & Insurance Your Visit COVID-19 Info Patient Forms Forms to Download and Print All forms must be returned to us by the patient/signer in person. General Forms: Sliding Scale Application New Patient Registration Form Permission to Share My Personal Health Information Permission to Release Medical Records Patient Complaint “Grievance” Form Parental Consent Form for Elsie Allen Advance Care Planning Packet Rights Responsibilities Grievance ENGLISH 09.19 HIPAA Notice of Privacy Practices rev 2014 – English – SRCH 08.17 Visit Specific Forms Tele-Dental Visit Instructions Well-Child Baby Visit Tele-Dental Visit Instructions: Visit Instruction Sheet in English Hoja de instrucciones en español Well-Child Baby Visits: 2 Month Visit: Staying Healthy Assessments (SHA) 0-6 months 4 Month Visit: ACES/PEARLS 6 Month Visit: No forms needed 9 Month Visit: ACES/PEARLS Staying Healthy Assessments (SHA) 7-12 months 12 Month Visit: ACES/PEARLS Staying Healthy Assessments (SHA) 1-2 yrs. Ages and Stages (ASQ) 15 Month Visit: Staying Healthy Assessments (SHA) 1-2 yrs. Ages and Stages (ASQ) 18 Month Visit: Staying Healthy Assessments (SHA) 1-2 yrs. Ages and Stages (ASQ) MCHAT 2 Year Visit: ACES/PEARLS Staying Healthy Assessments (SHA) 1-2 yrs. Ages and Stages (ASQ) MCHAT Your Visit Patient Forms Tips For Your Visit Make An Appointment Search Notice of Nondiscrimination Notice of Translation Services Notice of Privacy Practices Santa Rosa Community Health is an FTCA deemed facility. Santa Rosa Community Health is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. Locations Brookwood Campus 707-583-8700 Dental Campus 707-303-3395 Dutton Campus 707-396-5151 Elsie Allen Campus 707-583-8777 Lombardi Campus 707-303-3600 Pediatric Campus 707-578-2005 The Bridge Campus Referral Only Vista Campus 707-303-3600 MyCareOnline MyCareOnline can help you communicate better with your medical team, 24 hours a day. Sign In to MyCareOnline Contact Us Administrative Offices Mailing Address: 3569 Round Barn Circle Santa Rosa, CA 95403 Report a patient safety concern Join Our Mailing List ALERTA: Para recibir la vacuna COVID-19, hacerse la prueba o obtener información sobre los servicios de salud en SRCH.Haga clic aquí. +