Medical Records Release Form

 

Authorization form for MIPA to disclose records to third-parties

 

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New Patient Packet

 

Registration form, financial policy and privacy practices agreements, and past patient/family medical history.

 

Please complete the family medical history with as much detail as possible -- we can use this information for reference over the course of your child's life. As with all other patient records, it will be kept confidential.

 

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Change of Information Form

 

New address or insurance? Fill in your updated info on the registration form (you may leave other sections blank) and bring to your next appointment.

 

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School/Camp/Sports Forms

 

Sports participation, med-at-school, and other forms for local school districts.

 

Please complete the patient/history portion of forms prior to exam appointment - doctors are unable to complete and sign until you have done so.

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WA State Dept. of Health Medication Exemption Form

 

Form stating exemption from immunizations for religious, personal, philosophical, and medical reasons.

 

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If you wish to have any forms mailed back to you, please provide us with a self-addressed and stamped envelope.