Patient Forms

NOTE:  New patients under 18 years of age must be accompanied by a parent or guardian at their first visit.

New Patient Forms

New Patient Forms – Adult

New Patient Forms – Pediatric

General Forms (Formularios Generales)
Advance Directive

Acknowledgement of Receipt of Notice of Privacy Practices
Privacy Practices

Reconocimiento de haber Recibido el Aviso de Prácticas de Privacidad
Prácticas de Privacidad

Authorization for Release of Medical Information

Healthy Michigan Plan Health Risk Assessment

Medical Care Authorization and Consent for Treatment
Autorización de atención médica y consentimiento para el tratamiento

Medicare Wellness Visit Assessment

Sliding Fee Discount Application
Aplicación para el Programa de Descuento

Pediatric Forms (Formularios de Pediatría)
Pediatric Demographics
Datos Demográficos de Pediatría

Pediatric History

Patient Eligibility Screening Record – Vaccines for Children Program
Registro de Revisión de Elegibilidad del Paciente – Programa de Vacunas para Niños

Adult Forms (Formularios de Adultos)
Adult Demographics
Datos Demográficos del Adulto

Adult Patient History

Dental Forms
Dental Health History

Portable Dental Services 2023-2024
Servicio Dental Móvil 2023-2024

Behavioral Health
Behavioral Health Counseling Services Packet

Student Health Center Forms
Student Health Center Forms Packet