WASSAJA CLINIC FORMS

Please print and fill out the appropriate forms and bring them with you to your appointment.

Wassaja Clinic New patient and clinical forms

Please print and fill out both of these new patient forms and bring them to your first appointment.

new patient form

WMHC Demographics Form

Please print and fill out both of these new patient forms
and bring them to your first appointment.

new patient form

WMHC Health History Form

Please print and fill out both of these new patient forms
and bring them to your first appointment.

Clinical Care Forms

Blood Glucose Log

Please print and fill out both of these clinical
care forms and bring them to your appointment.

Wassaja Clinic Consent Forms

Consent Forms

Consent to Treat Form

Generally all patients under 18 years of age must be accompanied to all appointments by a parent or legal guardian. We understand that it is sometimes necessary for babysitters, friends, or relatives to bring a child in to be seen. It is also sometimes necessary for an older teen to come by him or herself. In these cases, the parent or guardian must either submit a signed note, a power of attorney, or fill out a Consent to Treat form.

Consent Forms

18 Years and Older Consent Form

By law 18 year olds are adults. As adults, they have the right to keep health records confidential (regardless of who pays for their insurance or whether they live at home). Our doctors and nurses believe parents should be partners in their children’s care at every age. However, it is up to the patient to whom he/she gives permission to share privileged information.

Wassaja Clinic Administrative forms

administrative form

Health Information
Release From WMHC

Authorizes release of medical records from
Wassaja Memorial Health Center

administrative form

Health Information
Release To WMHC

Authorizes Wassaja Memorial Health Center
to request medical records

administrative form

WMHC Name Change
Request Form

Please submit this form along with requested
documentation to change your name in our records

administrative form

Advance Directives Form

In times of serious illness, it is important to start important conversations about end of life care. A living will tells your family and doctor how you want to be cared for when you are no longer able to. This includes who you want to make health care decisions for you, the kind of treatment you do and do not want, and how you want people to treat you. For more information visit: www.agingwithdignity.org/five-wishes.php

Our Programs

Learn more about our asthma & diabetes programs

Healthy Futures

Stay up-to-date with our Healthy Futures new blog

Our Services

Learn more about our clinic & community health services

CONTACT US

In emergency situations always call 9-1-1. For non-emergency situations you can reach the Wassaja Memorial Health Center at 480-789-7890.

CALL 9-1-1 IMMEDIATELY FOR:

For Life Threatening Emergencies &
Medical Attention

OTHER EMERGENCY PHONE NUMBERS

Poison Control Center: 602-253-3334
Behavioral Health Emergency (EMPACT): 480-461-8888

Disclaimer: The information on this website is a supportive service to Wassaja Memorial Health Center and is not meant to replace the advice of a physician who provides your health care. All medical information and advice on this website is considered incomplete without a physical exam and consultation with your doctor.