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870.425.5010
Main: 870.424.2442
Pharmacy: 870.425.5017
421 W Wade Ave
Mountain Home, AR 72653
Tue - Thu | 9AM - 3PM
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Patient Forms

The following PDFs are the patient forms that patients will be required to fill out. If you desire, you can print these ahead and time and have them filled out prior to coming into the clinic.  ALL patients must come in to register for eligibility in person.  

 

Request for Assistance Form

Medical Records Release

Sight Care Assistance Application

PHQ-9 Depression Form

GAD-7 Anxiety Form