New Patient Forms Available Online

 

These form links are only for a patient's first visit to our practice; after the first visit you do not need to worry about these forms because we will keep them on file in our office. If you would like to get a headstart with the forms you will need to make your first visit run more smoothly, please feel free to print out the following forms you will need and fill them out prior to your scheduled visit. If there is any question about which forms you may need, please call our front desk and our staff will direct you to the right quick link (810-424-5269). These forms are NOT required to be filled out prior to your visit; instead, we have copies at our front desk and you may fill them out when you arrive for your appointment.

Please click on the desired form icon pictured below:

 

 

Health History Form

We use this form to gather your past and present health information. This information is very important for keeping records and treating you to the best of our ability. Your health history helps us to decide how to best help you and improve your health. It allows us to make the most well-informed decisions about your diagnosis and treatments. From your first visit, we will have a strong understanding of your situation so we can begin to develop the best methods for maintaining and improving your health. This information must be kept on file while you are a patient at our practice.

Acknowledgement Form

This form indicates that we have shared with you, the patient, our policies and procedures; it confirms this communication and also that you have understood and accepted them. It is needed for addressing co-pays if any are due, gives us permission to contact your insurance company, and to treat you. It also lets you know that we will keep your information private. This form is also required for your file.

Notice of Privacy Practices Form

This form is a required part of your file as a patient; it is kept on file because it ensures that every patient is informed of the privacy practices of the Urban Health and Wellness Center. This form indicates how we will safeguard your information, what we will or will not disclose and to whom, and under what circumstances we will conduct such activities. It also indicates that these policies are openly available upon your arrival and are available if requested at any time. To read this full document, click here.

Records Release Form

This form is NOT required for your first visit but it is required by law if you want us to pass your medical records on to a third party. Your health records will be released only with your written consent if you are 18 years old or older, or an emancipated minor. An emancipated minor is defined under Michigan law as being married, emancipated through a court order, or on active duty in the armed forces prior to age 18. If you are less than 18 years old, the UHWC is obligated by law to release health records to your parents if they request them, with the exception of those records related to sexually transmitted diseases, contraception, and/or pregnancy testing.

 

All of the forms on this page are in PDF format. This is a free download and it is required before you will be able to open these files. If you do not already have Adobe PDF Reader on your computer, please download it from the Adobe link to the right; it should only take a couple minutes on a highspeed connection. You may use the free version for viewing and printing hardcopies of these forms: