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Departments

These are the forms Central Montana Family Planning and our satellite office in Roundup require in order to establish and/or maintain your healthcare with our clinic.

Feel free to download, fill-in (when applicable), print-out, sign, and return to us at your appointment time.

 

FORMS MUST BE FILLED OUT IN EITHER BLUE OR BLACK INK ONLY.

Forms Required at First Visit, Annually, or Whenever Address and/or Income Changes

Data Sheet  

Medical Services & HIPAA Acknowledgment, *First visit or if legal name changes

Forms Required at First Visit Only ~

Female Health History *not a fill-in form

Male Health History *not a fill-in form


Forms Required if You've Had an Exam Within the Last 12 Months with Another Provider

Medical Request or Release form


Forms Needed if Your Plan on Using Your Parental Income and/or Insurance

Parental Insurance Consent


Forms Needed to Allow or Deny Parental/Guardian Information About Your Patient Status

Patient Information Parental Release


♦ Client Satisfaction Survey ♦

Please fill out and either mail or drop off, survey is ANONYMOUS. Thank you!

SURVEY

Birth Control Method Information & Consent Sheets* ~

Your method of choice will be discussed at length at your appointment. You'll be required to sign a consent for your preferred birth control method.

"The Shot" Depo Provera Hormonal Injection

"The Ring" NuvaRing

Oral Contraceptive Pills

Oral Contraceptive Pills Progestin-Only "The Mini Pill"

Plan B Emergency Contraceptive

 

Central Montana
Family Planning
505 W. Main Street
Suite #108
Lewistown, MT 59457

Musselshell County
Family Planning
1207 2nd Street West
Roundup, MT 59072

Contact
Phone & Fax: (406) 535-8811
Toll-Free: (877) 421-8646

Office Hours, Lewistown
Monday - Thursday:
  8 AM to 5 PM
Fridays:
  8 AM to Noon

Office Hours, Roundup
Call for Appointment


Sue Irvin
Director

Dr. Christina Marchion
Medical Director

Denise Butcher
Registered Nurse

Sharon Gottardi
Nurse Practitioner

Dan Muniak
Physician Assistant-Certified

Allison Smith
Receptionist

Satellite Office

Valeri Russell
Physician Assistant-Certified

Brynn Bixby
Physician Assistant-Certified

Deborah Shields
Physician Assistant-Certified

Laurie Shanks
Registered Nurse