New Patient Forms
Download and fill out each form to bring to your first appointment. If you do not, please come to your appointment 20 minutes early to fill them out at the office.
1) Patient Health History. The Health History form for both adults and children is important to fill out completely for your provider so that they have a complete picture of your health. There are separate forms for your medical health history and dental health history.
2) Consent for Treatment: White House Clinics requires all patients to complete documentation that verifies their consent to the treatment provided.
The Consent for Treatment Form (Adults / Pediatrics) does the following:
- Gives White House Clinic providers permission to treat you
- States that you agree to pay for services and allows White House Clinics to bill and collect payment from your insurance provider
- Acknowledges that you have received a copy of our Privacy Notice
Patients who are 17 years and younger or adults with a guardian must also have minor consent form on file with us. The Minor Consent Form tells our staff who the legal guardian is as well as who can bring the child to appointments. If you anticipate ever needing a relative or neighbor to bring your child to an appointment you can use this form to indicate who you authorize to do this. This form also tells us what school or daycare your child attends so that we can send paperwork like school excuses and shot records directly to the school or daycare – saving you a trip to our office.
3) The Patient Communication Form lets our office know how you would like for us to contact you in regard to your health information (appointment reminders, test results, referral information). It also tells our staff if they can leave you a message or if there is anyone like a spouse, child, or friend that our staff can discuss your appointments, billing concerns, or other health information with when you are not available.