| Patient Visit Forms |
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| Copyright © 2008 by Wellness Center of Door County, Inc. All rights reserved. Website created by TSB & MGB |
 | Patient Profile (Name, Address, Phone, Financial Info, etc) |
| FEMALE Health Assessment (Must be completed for 1st visit) |
| Consent to Treat/ HIPAA Privacy Form |
| Records Release Form |
| MALE Health Assessment Form (Must be completed for 1st visit) |
| Consent for Birth Control (Must be completed to receive birth control) |
| Request for Birth Control by Mail Form |
| Sue Baldwin Fund Application | |
The following information is in PDF format. You will need the
latest version of Adobe to read the files. Click here to
download Acrobat Reader.
latest version of Adobe to read the files. Click here to
download Acrobat Reader.
IF YOU'RE A 1ST TIME CLIENT YOU WILL NEED TO COMPLETE:
BIRTH CONTROL FORMS
ASSISTANCE FOR ABNORMAL BREAST FINDING EVALUATION
(in males and females)
(in males and females)