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Forms

Patient Forms for Public Health


DENTAL

Consent for Services

Permission to Delegate Dental Treatment and Disclosure of Health Information

Policies and Procedures

Patient Medical History

NEEDED FOR ALL CLINICAL SERVICES

Demographics Form (English/Spanish)

BREAST AND CERVICAL CANCER

Demographics Form (English/Spanish)

List of Acceptable Documents for Proof of Identification

List of Acceptable Documents for Proof of Income

FAMILY PLANNING

List of Acceptable Documents for Proof of Identification

List of Acceptable Documents for Proof of Income

Demographics Form (English/Spanish)

Female Reproductive Health History

IMMUNIZATION

Demographics Form (English/Spanish)

List of Acceptable Documents for Proof of Income

WIC

WIC PreScreening Tool

List of Acceptable Documents for Proof of Identification 

List of Acceptable Documents for Proof of Income

List of Acceptable Documents for Proof of Residence 

PROVIDER FORMS FOR PUBLIC HEALTH

Communicable Disease

Communicable Disease Reporting Form and Instructions for Providers

Animal Bite Report Form for Providers


  1. Breast & Cervical Cancer Control Program (BCCCP)
  2. Child Health
    1. CC4C
    2. School Health
  3. Dental
  4. Disease Testing & Tracking
  5. Family Planning Services
  6. Health Education & Healthy Haywood
  7. Immunization for Children, Adults & Travlers
  8. Physical Exams & Testing
  9. Pregnancy, Prenatal Care & Education
  10. WIC Nutrition Program
  11. Forms
  12. Resources in Haywood County
  13. COVID-19 Economic Resources
Agendas & Minutes
Apply for Jobs
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  1. Haywood County Blue Ridge 1808 Great Smokies

Contact Us

  1. Haywood County Government
    215 N Main Street
    Waynesville, NC

    Contact Us

Municipalities

  1. Town of Canton
  2. Town of Clyde
  3. Town of Maggie Valley
  4. Town of Waynesville
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