|
Form Name |
Format* |
|
Dysphagia Disorder Survey Request |
 |
 |
|
|
|
|
Intensive Technical Assistance Request Form
(instructions) |
 |
 |
|
|
|
|
Health Care Representative Form |
 |
 |
|
|
|
|
Individualized Feeding Plan Form |
 |
 |
|
|
|
|
Lifetime Medical History Form |
 |
 |
|
|
|
|
Triage Cards |
Not
Available |
 |
* All of our downloadable forms are available in two different formats:
MS Word format is a "fill-in-the-blanks" form that allows the user to complete the form on their computer and print or email.
PDF format allows the user to print a blank form to be completed by hand.
Need Adobe Reader? Click button below!

To Use Intensive TA Request Form
Fill out form and send by e-mail:
Click on MS Word version of the form.
You will see the following dialog box:

Click on Save to save the document to your computer.
Fill-out required information.
Save completed document to your computer.
To e-mail, click on File, then Send To, then Mail Recipeint (as attachment)
Send to info@hcqu.org
Print form and send by fax or mail:
Click on PDF version of form. You will see the following dialog box:

Click on Open.
Print Form and complete by hand.
Fax to
(724) 283-1012 OR
Mail to:
Community Health Connections
120 Hollywood Drive, Suite 201
Butler PA 16001