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Printable Forms
for our patients

Please return completed forms to your provider at your next appointment or mail them to:

Eau Claire Medical Clinic
703 W. Hamilton Ave.
Eau Claire, WI 54701

 

Please see below to find a list of downloadable forms that will help you get started as a new patient with Eau Claire Medical Clinic. All other forms will be provided to you upon your first visit with us.

 

New Patient Forms

Assignment of Insurance BenefitsDownload PDF

Family Shared InformationDownload PDFDownload PDF

Patients can authorize the release of their confidential
health information to a family member using this form.

Health HistoryDownload PDF

Insurance Information for New PatientsDownload PDF

Patient Demographics FormDownload PDF

 

General Forms

Consent for Treatment of Minors in Parent/Legal Guardian AbsenceDownload PDF

Eau Claire Medical Clinic requires that a parent or legal guardian consent to the care of minor children. In the event that a parent or legal guardian is unable to consent to care the parent or legal guardian delegate the right to consent to another adult.

Pediatric Health HistoryDownload PDF

Release of Information AuthorizationDownload PDF

Patients can authorize the release of their confidential health information using this form.

Privacy AcknowledgementDownload PDF

 

We have made our forms available to you as Adobe Acrobat files for your convenience. When you click on the name of the form, it will automatically open in Acrobat Reader. Make sure you use the print button in Acrobat so the forms will print correctly.