Forms available for downloading
1st Visit Patient Information Form  
(English Form) OR  (Spanish Form)
1st Visit Patient Consent Form  
(English Form) OR  (Spanish Form)
Family Planning, Women's Health Form
(English Form) OR  (Spanish Form)
Family PACT Application Form
(English Form) OR  (Spanish Form)
Family  PACT Male Form  
(English Form) OR  (Spanish Form)
Family PACT Female Form
(English Form) OR  (Spanish Form)
DMV  Medical  Examination
(DMV Site Forms)
Frequently Ask Questions
Question: What do I need to bring on my first visit?

You need to bring any photo ID, and you may also bring your Family PACT  card and/or medical card. Also for
faster service you may fill up and bring some of the forms from our site.
For information in obtaining the Family Pact and Medical card please call our office.
Question:  What are the free services that your clinic offers?

If qualify,  we offer Family PACT services; this includes free pap smear and mammogram screenings, sexual
transmitted diseases, birth control methods, and medications. We also offer children vaccines, prenatal care,
classes, vitamins, ultrasounds, and a 4D ultrasound to our moms who attend our classes.
Question:  How do I qualify for your free services?

Set up an appointment or come in to our office, the receptionist will have you fill out some forms and ask you few
questions regarding your income, family size, age, birth control, and insurance information if any.
Question: I am a teen, all your services are confidential?

Family PACT program provides confidentiality to all our patients regarding STI testing and pregnancy test or any
services render at our office within this program. At our office we follow HIPPA regulations regarding our patients
confidentiality and privacy.  A copy of HIPPA regulation may be obtained at our facility.
Question: Do you accept walk in?

Yes, we are more than glad to see  you at your convenient time; however our scheduled appointment will take
preference; But we always accommodate you, and attend your needs at a timely manner.
Question: Do you offer transportation?

Unfortunately, we don't offer transportation at this time. But since we are in a major street, many bus routes are
near the clinic.
Question: At which Hospitals can I have my baby?

Thomas T. Lee, our OB/gyn doctor deliver our patients at Pomona Valley Medical Center, Pomona CA., and
Doctor’s Hospital of Montclair, at Montclair CA.
Question:  I am pregnant how can I start my prenatal care?

Set up an appointment with us, and we will more than help you to guide you step by step from the medical
application to cover your pregnancy to the post partum exam 40 days after delivery. We will help you to complete
the medical application, offer you WIC program which provides vouchers for nutritional needs for you and your
baby. If you qualify all prenatal services are free and you can take advantages of our educative prenatal classes.
To contact us:

Phone: (909) 623-7799
Fax: (909) 623-0663

E-mail: info@clinicafamilia.com
Health Clinic Salud Y Familia
Taking Care of your family’s Health
FAQ's & Forms