Patient Forms for all WWMG Practices

Please scroll down for all forms.

Arthritis

• 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

Clinical Laboratory

• Patient Registration Form

Diabetes & Nutrition

• Diabetes Referral
• Medical Nutrition Therapy Referral
• Insurance Checklist
• Self-Assessment

Ear, Nose and Throat / Allergy / Audiology

• Welcome Letter
• Patient Registration Form
• Medical Questionnaire
• Audiology Questionnaire
• Allergy Testing Questionnaire
• HIPAA Signature Page
• Cancellation Policy
• Financial Policy
• Everett ENT Records Request Form

Endocrinology Center

• New Patient Welcome Letter
• 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
• Patient History – New Patients
• Privacy Policy
• Notice of Privacy Practices
• Consent to Release Information
• No Show Policy
• Consent to Treat a Minor
• Office/Financial Agreement
• EFM – Authorization for Release of Information Form 2018

Lake Serene Clinic

• New Patient Registration
• 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

Snohomish Family Medicine

• DOT Exam Checklist
• DOT Exam Report
• Medical Examiner Certificate
• No Show Policy
• SFMC NPT Female
• SFMC NPT Male
• SFMC Pediatric Female
• SFMC Pediatric Male
• Wellness Forms Female 
• Wellness Forms Male 

Whitehorse Family Medicine

• Packet for Minors – This packet is specifically for patients under the age of 18.
• Packet for Adults
• Consent to Treat a Minor
• Authorization to Release Records
• No Show Policy

Gastroenterology / Endoscopy

• New Patient Packet
• Return Patient Packet
• Primary Packet
• Release of Records Authorization

Nephrology

• New Patient Instructions
• Patient Registration
• Health History
• Financial Agreement
• Consent to Release Information
• Patient No Show Policy
• Privacy Policy
• Acknowledgement of Receipt of Notice of Privacy Practices

Orthopedic

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

Podiatry

• New Patient Packet
• Notice of Privacy Practices
• Consent for Minors
• Authorization for Release of Information
• Refurbishment of Orthotics

Psychology

• New Patient Registration Form

Pulmonary / Asthma

• Appointment Policy – Pulmonary
• Patient Registration Form
• Consent to Release
• Financial Agreement
• General Information
• General Information Edmonds
• Patient Questionnaire
• Patient Health History
• Privacy Policy
• Acknowledgement of Privacy Practices

Rheumatology

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

Sleep Medicine

• Appointment Policy – Pulmonary
• Patient Registration Form
• Consent to Release
• Financial Agreement
• General Information
• General Information Edmonds
• Patient Questionnaire
• Patient Health History
• Sleep Questionaire
• Privacy Policy
• Acknowledgement of Privacy Practices

Surgery Center

• New Patient Registration Form