BHS Health Center Network is a network of community clinics providing low cost health care. We use a sliding fee scale that is calculated based on income and household size to determine costs for our patients. Regardless of your ability to pay, we proudly serve all patient demographics and are required to obtain the following confidential and protected information due to federal regulations. We appreciate your cooperation with these yearly requirements.


Living Arrangements *

Please select one



Pharmacy Information
Previous Physician





Emergency Contact

If different from Parent/Guardian or Spouse *

You have written instructions regarding your medical care if you fall ill.

You have appointed someone to make medical decisions for you when you are unable to.


How were you referred to our clinic? *
Print Full Name *