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Departments

These are the forms Central Montana Family Planning requires 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

Forms Required at First Visit Only ~

Personal Health History


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

Parent Financial Form


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

Teen Patient Parent/Guardian Release 

Birth Control Method Information

Your method of choice will be discussed at length at your appointment. 

 

Central Montana
Family Planning
300 1st Ave North
Suite 202
Lewistown, MT 59457

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


Sue Irvin
Director & Health Educator
Cancer Control Specialist

Dr. Christina Marchion
Medical Director

Denise Butcher
Registered Nurse

Dan Muniak
Physician Assistant-Certified

Deborah Shields
Physician Assistant-Certified

Sharon Gottardi 
Nurse Practioner

Allison Smith
Receptionist