Patient Forms

Lowell Community Health Center makes it easy for you to access and complete patient forms. Start by clicking on the form you need below. For many of our forms, we are now offering an easier, secure virtual system that allows to submit your form electronically. No PDFs to download and print! If you need immediate attention, such as for prescription refills, please call 978-937-9700. Our Patient Walk-In Center is also open from 8 AM to 2 PM Monday through Friday.

If you select one of our HEALTH INFORMATION Virtual Forms…

1. After clicking the form, you will be asked to provide your name and email. This will allow you to edit and sign your form and communicate with Health Information.
2. Once the form is submitted it will be sent directly to Health Information. You do NOT need to email a copy. 

If you select one of our PDF Forms (MA Healthcare Proxy, Pediatric Assessment Forms and COVID Vaccine Consent) ….

1. Print the form, fill it out, and sign it.
2. For COVID-19 Vaccine Consent Forms, simply bring it with you when you come for your vaccine. 
3. Pediatric Forms: Return it to us by mail to:

   Lowell Community Health Center
   ATTN: Health Information
   161 Jackson Street
   Lowell, MA 01852

   or fax to 978-221-6728. If you have Adobe, you may also be able to complete electronically and email to Health Information. 

We will respond to all requests within three business days. If you have questions, please call 978-937-9700 and ask to be connected with Health Information.

HEALTH INFORMATION Virtual Forms 

• MOLST Form (Medical Orders for Life-Saving Treatment)

  Display Name: 

  MOLST Form (Medical Orders for Life-Saving Treatment)

Records Request/Release

• Release of Records (can be used for billing records requests)
  Release of Records (Spanish) (can be used for billing records requests)

• Medical Record Request
• Medical Record Request (Spanish)
• LHS Consent
• Stoklosa Consent

MA Healthcare Proxy (available as PDF download only)

MA Healthcare Proxy