Medical & Dental Sliding Fee Application

Sliding Fee Application (English & Spanish)

Medical Forms

General Consent for Treatment 2019
Notice of Privacy Policies
Patient Medical History 2019
Patient Registration 2021
General Consent for Treatment 2019 (Spanish)
Notice of Privacy Policies (Spanish)
Patient Medical History 2019 (Spanish)
Patient Registration 2021 (Spanish)

Dental Forms

General Consent for Treatment
Notice of Privacy Policies
Patient Demographics
Patient Information
Patient Medical History
General Consent for Treatment Dental (Spanish)
Medical History (Spanish)
Notice of Privacy Policies (Spanish)
Patient Demographics (Spanish)
Patient Information (Spanish)

Our Mission Statement

“MERCE Family Healthcare is a non-profit organization that seeks to provide primary medical, behavioral health, urgent care, dental and patient education services, as well as the coordination of additional support resources to medically and dentally underserved citizens of Randolph County and the surrounding area.”

NOTICE TO PATIENTS: This practice serves all patients regardless of their inability to pay. Discounts for essential services are offered based on family size and income. For more information, please ask the front desk staff at any of our locations.