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Forms

Income Worksheet – Please print, fill out and bring with you to your appointment

Request to Receive Family Planning Screening Services – Please print, fill out and bring with you to your appointment

Release of Records – Please print, fill out and mail or fax to MyAlly Health

ND Sports Physical Form

MN Sports Physical Form

Information on Colposcopy

Resources

ND State Family Planning

Healthy Families

Community Violence Intervention Center (CVIC)

Centers for Disease Control and Prevention

ND Department of Health Tobacco Cessation

Grand Forks County Social Services

March of Dimes

North Dakota Cancer Coalition (NDCC)

Interpreter Services – Available at no cost to the patient in their language of origin

Notice of Privacy Practices

701.757.2559

If you are searching for healthcare providers who are both professional and judgement-free, you have come to the right place. MyAlly Health provides the Red River Valley and surrounding areas with confidential reproductive health services, counseling and education.

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4700 South Washington Street, Suite C | Grand Forks, ND 58201

© 2019 MyAlly Health. All Rights Reserved.

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