Patient Forms
Forms for New Patients
adult-patient-information 2012: A medical history form that you can print out, fill in and bring with you to the clinic.
Obstetrical Medical History Form and Gynecological Medical History Form
Pediatric Medical History Forms – please select the appropriate form based on your child’s current age:
Authorization for Disclosure of Medical Information: Use this form to have your records transferred from another medical care provider to Northfield Hospital & Clinics. Please fill it out, sign it and submit it to your previous provider.
Adult Health Maintenance Form: A record of your immunizations, lab work and diagnostics to bring with you to the clinic.
Other Forms
Minor Consent Form: A parent/guardian’s authorization for someone else to bring their child to the clinic for medical care and treatment.
Authorization to Release Medical Information (to another medical provider): Use this form to have your records from Northfield Hospital & Clinics (including FamilyHealth Medical Clinic) transferred to another medical care provider. Please print and fill it out, sign it and submit it to the clinic that has the records you want transferred.
Living Will
Minnesota Health Care Directive: Also known as a living will, a legal document that allows you to name an agent to make healthcare decisions for you in the event y0u are unable to make them yourself; you can also authorize organ or tissue donation.
Minnesota Health Care Directive attachment – Healthcare Instructions: An optional attachment to the form above, where you can specify treatment preferences and instructions to guide your healthcare agent.
