Medical Clinic Patients

Please fill out these forms and bring with you to your first visit to expedite the registration process.


Dental Clinic Patients

Please fill out these forms and bring with you to your first visit at our dental clinic to expedite your registration.


School-Based Health Clinic (SBHC) Forms

NOTICE: There are separate forms for students & school faculty/staff.

Monroe County Schools

(Hatley | Smithville | Hamilton)

Pontotoc Schools

(North & South)

Okolona Schools

(Elementary & High School)


Sliding Fee Discount Program

(Patient Financial Assistance)

When approved, you will receive a percentage discount* on services.
To apply, fill out these forms and return them to any AFHS clinic.

* Discount is based on family size and income. Proof of income is required. If you have $0 income, there is a Support Form included in the application packet to be filled out by the person who pays your bills and expenses.