Patient Information & Forms
Additional Patient Information & Forms
Please download, print, and complete the following Adobe Acrobat PDF form:
Use this form to authorize Family Wellness Center providers to communicate your protected health information to another person or facility.
All new patients must complete this form to set up an individual account with Family Wellness Center. Bring completed form along with your insurance card with you to your first appointment.
For annual physicals, complete this form and bring it with you to your appointment.
Children & Teens Under Age 18 form
A parent of a NEW pediatric patient should complete this form and bring it to their child’s first appointment at Family Wellness Center.
Medical Records Release TO Family Wellness Center
If you are requesting that your records come TO Family Wellness Center.
The difference between a preventative care visit, a problem based visit and having a secondary service at a preventative care visit.
What’s Happening01/08/18 Family Wellness Center to Join Legacy Medical Group in April of 2018
Family Wellness Center to Join Legacy Medical Group in April of 2018 after 2312/21/17 Clinic Closures on Monday, December 25, 2017 and Monday, January 1, 2018
The clinic will be closed on Monday, December 25, 2017 and Monday, January 1,12/21/17 Tuberculosis Testing Recommended for Wy’east Middle School.
Tuberculosis testing for 187 students and staff members at Wy’east Middle Sc