Please print and fill out both of these new patient forms and bring them to your first appointment.

WMHC Demographics Form

 WMHC Health History Form

Consent to Treat Form: Generally all patients under 18 years of age must be accompanied to all appointments by a parent or legal guardian. We understand that it is sometimes necessary for babysitters, friends, or relatives to bring a child in to be seen. It is also sometimes necessary for an older teen to come by him or herself. In these cases, the parent or guardian must either submit a signed note, a power of attorney, or fill out a Consent to Treat form.

18 Years and Older Consent Form: By law 18 year olds are adults. As adults, they have the right to keep health records confidential (regardless of who pays for their insurance or whether they live at home). Our doctors and nurses believe parents should be partners in their children’s care at every age. However, it is up to the patient to whom he/she gives permission to share privileged information.

Health Information Release From WMHC: Authorizes release of medical records from Wassaja Memorial Health Center

Health Information Release To WMHC: Authorizes Wassaja Memorial Health Center to request medical records

WMHC Name Change Request Form: Please submit this form along with requested documentation to change your name in our records

Advance Directives Form: In times of serious illness, it is important to start important conversations about end of life care. A living will tells your family and doctor how you want to be cared for when you are no longer able to. This includes who you want to make health care decisions for you, the kind of treatment you do and do not want, and how you want people to treat you. For more information visit: www.agingwithdignity.org/five-wishes.php