The following forms may be downloaded in PDF format.
For NEW PATIENTS: Please print, complete, and bring these forms with you to your first visit based on your age. This will help to decrease the time you spend on administrative paperwork in the doctors office. Please also arrive 15 minutes prior to your stated appointment time. We look forward to meeting you!!
- Patient Intake Forms (please pick form based on your age)
- Patient-History-Form 12-21 Years Old
- Patient-History-Form 22-39 Years Old
- Patient-History-Form 40-64 Years Old
- Patient-History-Form 65-105 Years Old
- Parental Information for Patients Under 18
- Medical Treatment of a Child Consent
*see Child Consent Form below.
For EXISTING PATIENTS who are scheduled for an annual wellness exam (annual physical), we will need updated forms (2) in your chart. Please print and complete these forms to expedite your check-in process. If it has been longer than a year since your last appointment, please arrive 15 mins prior to your stated appointment time.
Annual Wellness Forms
- Physical Form 10-12 Years Old
- Physical Form 13-20 Years Old
- MEDICARE – Annual Wellness Exam Questionnaire
- All Non-Medicare Patients
If you need a form to release medical records to be forwarded to our practice or for us to release records to another practice, please download
Parents and guardians of minors under the age of 18 will need a form completed to authorize any other individuals (other family members, adult supervisors, etc) to consent to treatment of that minor on their behalf during a visit when the parent is not present. This would also allow those appointed agents to pick up forms/prescriptions/records/etc. and consent to medical treatment (immunizations/lab draws/procedures) on that parent’s behalf.
All patients who would like to complete a form related to end-of-life advanced directives should print and review this form. This form will need to be reviewed and signed in the presence of your provider but should be discussed with family or guardian prior to your appointment.
If you have a motor vehicle accident related appointment, please print this form and bring to your visit. We will need your auto insurance information even if the fault is to the other driver.
If you have a worker’s compensation related appointment, please print this form and bring to your visit.
If you need a Blood Sugar Journal
If you need a Blood Pressure Journal
Narcotic/ Opioid/Controlled Substance Policy – signing this agreement does not guarantee that you will be prescribed controlled medications at your visit.
BW Primary Care HIPAA- Privacy Practices