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.
WellOne’s Welcome Packet
WELCOME_PACKET2023-1678814217.pdf
Adult Health History Form
adulthealthhistory2018-1517594837.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
Application For Reduced Fee Services
Sliding_Fee_Application_2021_dh-1621963734.pdf
Medical Records Release Authorization Form
wellone_release_of_information_form_0818-1534426150.pdf
Dental Medical Release Form
2023_Dental_release_of_information_wellone-1678814161.pdf
HIPAA Notice of Privacy Practices
HIPAA_Notice_of_Privacy_Practices_clean_04012022-1646854318.pdf
Patient’s Rights and Responsibilities
rights_and_resposibilities_WellOne-1621611886.pdf
Your Right to Receive a Good Faith Estimate
WellOne_GFE_waiting_room_web_site_disclosure-1640291548.pdf