Patient Forms for all WWMG Practices

Please scroll down for all forms.

Arthritis

• The Arthritis Clinic-New Patient Packet

Cardiology

• Patient Registration Form
• Consent to Release Information
• Fee for Records Policy
• New Patient Appointment Letter
• Privacy Policy 
• No show/Cancellation Policy

Diabetes & Nutrition

• D&N –  WWMG Patient Demographics Form
• D&N – Self Assessment of Diabetes Management
• D&N – WWMG Consent to Release Information to Friends and Family
• D&N – WWMG Financial Agreement and No-Show Fee
• D&N – WWMG Notice of Privacy Practices and Acknowledgement Form
• D&N – Patient No-Show and Appointment Cancellation Policy

Ear, Nose and Throat / Allergy / Audiology

• Welcome Letter
• Medical Questionnaire
• Audiology Questionnaire
• HIPAA Signature Page
• Cancellation Policy
• WWMG-financial-agreement

Endocrinology Center

• Patient Medical History Form
• Patient Registration Form
• Medication Flowsheet
• Financial Agreement
• Acknowledgement of Privacy Practices
• Patient No-Show/Cancellation Policy

Family Practice

Everett Family Medicine

• Patient Registration Form
• Patient History – New Patients
• Privacy Policy
• Notice of Privacy Practices
• Consent to Release Information
• No Show Policy
• Consent to Treat a Minor
• Financial_agreement
• EFM – Authorization for Release of Information Form 2018

Lake Serene Clinic – Lynnwood

• Patient Registration Form
• DOT Physicals
• Parental Consent Form
• MVA Payment Authorization
• PHI Disclosure Authorization
• Routine Preventative Healthcare Checklist
• Wellness Exam Insurance Info
• Privacy Policy 
• No Show Policy

Marysville Family Medicine

• Adult Preventative Care 2018
• New Patient Packet
• Integrative Medicine Intake Form
• Consent to Treat a Minor
• Release of Information
• FMLA Disability Information Worksheet

Snohomish Family Medicine

• DOT Exam Checklist
• No Show Policy
• SFMC-NPT-Female
• SFMC-NPT-Male
• SFMC-Pediatric-Female
• SFMC-Pediatric-Male
• Wellness Forms Female 
• Wellness Forms Male 

Whitehorse Family Medicine – Arlington

• New-Patient-Packet-WFM-2
• WWMG Family Friends Consent
• Consent to Treat a Minor
• DOT Appt letter-WFM
• Wellness Exam – Female
• Wellness Exam – Male
• Review of Systems
• Pain Inventory Handout
• Med Hx Form
• COMM-Current Opioid Misuse Measure
• Generalized Anxiety Disorder Screening (GAD-7)
• PHQ.9 Form
• PHQ-A for adolescents
• Consent For Flu Vaccine

Gastroenterology / Endoscopy

• GI_new_patient_packet_
• GI_return_patient_packet_
• Primary Packet
• Release of Records Authorization

Nephrology

• New Patient Instructions
• Patient Registration Form
• Health History
• Financial Agreement – Nephrology
• No Show and Cancellation Policy
• Consent_to_release_information
• Privacy Policy
• Acknowledgement of Receipt of Notice of Privacy Practices

Orthopedic

• Ortho-Intake-Forms
• Spine-Intake-Forms
• Physiatry-Intake-Forms
• Record Release

Podiatry

• Podiatry-New-Patient-Packet-1
• Notice of Privacy Practices
• Consent For Minors – Podiatry
• Authorization for Release of Information
• Refurbishment of Orthotics

Psychology

• Patient Registration Form

Pulmonary / Asthma

• Appointment Policy – Pulm
• Patient Registration Form
• Consent to Release
• WWMG Financial Agreement
• General Information
• General Edmonds Information
• PATIENT HISTORY QUESTIONNAIRE
• Patient Health History
• Privacy Policy
• Acknowledgement of Privacy Practices

Rheumatology

• Patient Registration Form
• WWMG Financial Agreement
• Patient Health History
• Release of Records Authorization

Sleep Medicine

• Appointment Policy – Sleep Medicine 
• Patient Registration Form
• Cognitive Behavioral Therapy for Insomnia
• Consent to Release
• WWMG Financial Agreement
• General Information
• Sleep Medicine General Information
• Patient Questionnaire
• Patient Health History
• Sleep Questionnaire
• Privacy Policy
• Acknowledgement of Privacy Practices

Surgery Center

• Patient Registration Form