Wellness Center of Door County, Inc

PATIENT VISIT FORMS

IF YOU'RE A 1ST TIME CLIENT YOU WILL NEED TO COMPLETE:

• Patient Profile (Name, Address, Phone, Financial Info, etc)
• FEMALE Health Assessment (Must be completed for 1st visit)
• Mid-Life Health Assessment for Females (40 & older)
• Consent to Treat/HIPAA Privacy Form
• MALE Health Assessment Form (Must be completed for 1st visit)

BIRTH CONTROL FORMS:

• Consent for Birth Control (Must be completed to receive birth control)
• Request for Birth Control by Mail Form

MISCELLANEOUS FORMS:

• ASSISTANCE FOR ABNORMAL BREAST FINDING EVALUATION (in males and females)

FAMILY PLANING SERVICES FOR MALES & FEMALES

• For Family Planning Services Only

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Si esta es su primera visita como paciente tendrá que completar:

• Perfil del Paciente (nombre, dirección, teléfono, información financiera)
• Consentimiento para Tratar / Forma de privacidad de HIPAA
• MUJERES Evaluación de la Salud (debe ser completada en su pprimera visita)
• MALE Formulario de Evaluación de la Salud (debe ser completada para el en sue primera visita)

FORMAS DE CONTROL DE LA NATALIDAD

• Consentimiento para el Control de la natalidad (Debe ser completado para recibir el control de la natalidad (anticonceptivos)
• El Dispositivo Intauterino (DIU) Forma de Consentimiento para el Paciente

Patient Services Quicklinks

• Patient Services Home
• Patient Forms
• Glossary
• Frequently Asked Questions
• Birth Control
• Emergency Contraception
• Pregnancy Testing
• STD Testing
• Pelvic & PAP Exams
• Colposcopy
• After a Sexual Assault
• Menopause & Mid-Life
• Male Services
• Mental Health
• Stop Smoking
• Vaccines/TB Skin Testing