The following forms are for patients of UW Medicine Neighborhood Clinics. Please bring the completed visit or history forms with you to your appointment.
Adult Health History Form
To be filled out by adult patients who are establishing care with a UW Medicine Neighborhood Clinics provider.
Anticoagulation Visit Form
This form should be filled out by Coumadin patients prior to each anticoagulation visit.
Diabetes Questionnaire
To be filled out by patients with diabetes prior to each diabetes visit.
Nutrition Questionnaire
To be filled out by patients prior to their first visit with the Nutritionist.
Pediatric Well Visit Forms
To be filled out by the parent/guardian of the child prior to his/her Well Visit Appointment at the UW Medicine Neighborhood Clinics. Please select the appropriate form below.
One-Month Well Visit Form
Two-Month Well Visit Form
Four-Month Well Visit Form
Six-Month Well Visit Form
Nine-Month Well Visit Form
One-Year Visit Form
Permission to Treat a Minor Without a Parent/Guardian Present
To be filled out and signed by the parent/guardian of a minor patient if that patient will be seen without the parent/guardian present.
Prenatal History Form
To be filled out by pregnant women who are establishing obstetrical care with a UW Medicine Neighborhood Clinics provider.
Preparing for Your Visit
To be filled out by all patients to help you prepare for your upcoming visit.
Release of Information Forms
Sports Physical Forms
Please refer to your school district's website for the appropriate Athletic Participation/Sports Physical forms.