Download Forms

If you would like to save time prior to your appointment at WellOne, please download the following forms and complete them before your appointment. If you recently visited one of our locations and have already completed the forms, there is no need to fill this out.

Adult Health History Form
Adult_Health_History_7_30_13-1379354687.pdf

Child Health History Form – New Patients
Child Health History

For Your Next Visit
For_Your_Next_Visit-1368728361.pdf

Adult Dental History Form
ADA_Adult_History_Form-1284755232.pdf

Child Dental History Form
ADA_Child_History_Form-1284755287.pdf

Reduced Fee Application (sliding fee scale)
Reduced Fee Application

Medical Records Release Authorization Form
releaseofinformationwellone-1375299417.pdf

HIPAA Notice of Privacy Practices
HIPPANotice_of_Privacy_Practices-1379345544.pdf

Patient’s Rights and Responsibilities
Patients_Rights_and_Resposibilities-1452188091.pdf