BHS Health Center Network is a network of community clinics that provide low-cost health care on a sliding scale. Costs for patients are determined by a sliding fee scale that is calculated based on income and household size. We proudly serve all patients, regardless of inability to pay. The following information is required for each patient due to federal regulations. All information is confidential and protected. We appreciate your cooperation with these requirements. We are required to collect this information each year.

Patient Information
Emergency Contact



COVID-19 Physical Form
Review of Symptoms

Have you experienced any of these symptoms recently? Please check YES or NO for each symptom listed.

History of exposure to someone with lab-confirmed COVID-19?
Emergency Warning Signs
Household and Contacts


Current Medications
Medical History


Family History

Social History

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