Patient Forms

To help you save time during your visit to our clinic, we’ve made our most common forms available on the web! Just print the forms, fill them out when convenient, and bring them along for your appointment.

New Patient Packet

The New Patient Packet contains all three forms that we ask our patients to fill out during their first visit. You’ll need Adobe Reader to view and print these forms.

New Patient Packet


Medical Records Form

Records Release: If you would like us to release your records to another physician, download and fill out this form and Fax to our office at (574)269-7444.

Records Release Form

Records Request: If you have records from another medical practice that would be helpful to our providers, download and complete this form and send it to your previous physician.

Records Request Form


Weight Wise Nutrition History Form

This form contains an overall medical history, with a focus on nutritional and lifestyle evaluation. This form is often used for patients interested in our weight management plans.

Medical History, Nutrition


Individual Forms

Each form included in the New Patient Packet is also available for individual download. You’ll need Adobe Reader to view and print these forms.

Registration Form

Patient Health History

HIPAA Acknowledgement

 
 
 



COVID-19 Notice

In an effort to protect our patients, WWC is requiring all patients wear a mask, come alone to their appointment, and observe social distancing practices while visiting our office.

You will be screened upon entering the office. Per CDC recommendations, if you came in contact with COVID-19 or have a cough or fever, please call the office and speak with a nurse.

If our waiting areas become crowded, we may ask patients to please wait in their vehicles until we call them.