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