Below you’ll find forms that may be applicable to your primary or specialty care appointment or procedure. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit.
General UW Medicine
- Email Consent
- Notice of Privacy Practices Acknowledgment
- Patient Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity
- Patient Authorization to Disclose, Release and/or Obtain Protected Health Information
- Patient Authorization to Leave Personal Health Information by Alternate Means
- Patient Authorization to Use and Disclose Protected Health Information for Publication
- Patient Authorization to Use or Disclose Photography/Video
- Request to Consider Additional Privacy Protection for Protected Health Information
- Request for Correction or Amendment of the Medical Record
- Request to Restrict Disclosure of Healthcare Items or Services to Health Plans When Patients Self-Pay Out of Pocket
Primary Care
- Adult ADHD Packet
- Anticoagulation Visit (before each anticoagulation visit if on Coumadin)
- Diabetes Questionnaire (before each diabetes visit)
- NICHQ Vanderbilt Assessment Scale - Parent Informant
- NICHQ Vanderbilt Assessment Scale - Teacher Informant
- NICHQ Vanderbilt Assessment Follow-up - Parent Informant
- NICHQ Vanderbilt Assessment Follow-up - Teacher Informant
- Medication history (new and established patients)
- New patient health questionnaire (adults)
- New patient health questionnaire (pediatric)
- Nutrition questionnaire (for first visit with a dietitian)
- Prenatal history (if starting pregnancy care)
- Preparing for Your visit (new and established patients
- Newborn Well Child Visit
- 2-4-Week-Old Well Child Visit
- 2-Month-Old Well Child Visit
- 4-Month-Old Well Child Visit
- 6-Month-Old Well Child Visit
- 9-Month-Old Well Child Visit
- 12-Month-Old Well Child Visit
- 15-Month-Old Well Child Visit
- 18-Month-Old Well Child Visit
- 24-Month-Old Well Child Visit
- 3-Year-Old Well Child Visit
- 4-Year-Old Well Child Visit
- 5-Year-Old Well Child Visit
- 6-Year-Old Well Child Visit
- 7-8-Year-Old Well Child Visit
- 9-10-Year-Old Well Child Visit
- 11-12-Year-Old Well Child Visit
- 13-21-Year-Old Well Child Visit
Specialty care
- Alcohol and substance abuse agreement
- Dental clearance for kidney pre-transplant evaluation
- Kidney pre-transplant patient agreement
- Kidney transplant demographic information
- Kidney transplant recipient selection criteria
- Patient acknowledgement for kidney, pancreas or kidney-pancreas transplant
- Transplant services blood pressure record
UW Psychiatry Patient Documents for Telemedicine Visits
New Patient Forms – Outpatient Psychiatry Clinic
Provided are links to forms for patients who are seeing a provider at the UW Outpatient Psychiatry Clinic. Please complete these forms and have them handy to review with your provider.
- New Patient Form – OPC
- OPC Initial Symptom Review
- Outpatient Psych Questionnaire
- Mood Disorder Questionnaire (MDQ)
- Drug Abuse Screening Tests
- Audit-C Questionnaire
- PCL-S PTSD Checklist
- PC-PTSD-5 Questionnaire
- Patient Health Questionnaire 9 (PHQ-9)
- Generalized Anxiety Disorder (GAD-7)
- ROS - Review of Symptoms
- Safety Plan Template
Telehealth Patient Info Sheet and Zoom User Guide
Provided are links to the forms for you to review prior to your initial appointment.
Questionnaires
Provided are links to the forms that you may need for your appointment. Please complete these forms and have them handy to discuss with your provider.
- Outpatient MRI screening | Arabic | Chinese | Japanese | Korean | Russian | Spanish | Vietnamese
- CT contrast injection patient questionnaire | Arabic | Chinese | Japanese | Korean | Russian | Spanish | Vietnamese
- Mammography screening | Chinese | Japanese | Korean | Russian
- Cardiac perfusion scan questionnaire
Advanced Manual Therapy and Sports Rehabilitation Clinic
For Valley Medical Center patient forms, please visit the VMC website.