FORMS

We have various forms that can be accessed from our web site. We encourage you to send these forms to our office electronically if possible by using either the Web page or the Word document. It is important that you understand that sending information via e-mail or our web site is not secure.

If you are concerned, please SAVE IT AS A FILE on a disk or simply print the form after completing it electronically. This saves us a great deal of time which helps us serve you in less time and at a lower cost! You can then mail it or drop it off at the office. If you choose to complete forms at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.

	Web	Word	PDF
Prescription Refill Request	X
New Patient History	X	X	X
Billing Information	X	X	X
Child Care Authorization (see explanation below)		X	X
Update Child's Health History 0-12	X	X	X
Update Child's Health History 0-12, New Patient	X	X	X
Update Child's Health History 13-18	X	X	X
Update Child's Health History 13-18, New Patient	X	X	X
Medical History	X	X	X
Patient Consent for Use and Disclosure of Protected Health Information	X	X	X
Release of Medical Information		X	X
Pregnancy Questionnaire	X	X	X
Preoperative History and Physical Questionnaire	X	X	X
Race and Ethnicity Questionnaire	X	X	X
WIAA Participation Physical Evaluation - please read this important notice regarding sports physicals	X	X	X
Advanced Directives - Declaration to Physicians - Wisconsin Living Will			X
Advanced Directives - Power of Attorney for Healthcare			X

Child Care Authorization
For your convenience we are including a form to be used when you are out of town and family or friends are caring for your under age children. When completed, this form allows another adult emergency responsibility for medical treatment of your child. Return to table.