New Patient Forms
Welcome to Jordan Valley! As a patient here, you will need to fill out a few forms. You can print these forms and fill them out before your appointment, or we will give you a copy to fill out at the clinic.
New Patient Paperwork
When you visit our clinic for the first time, you will fill out a form called “New Patient Paperwork.” You’ll also update this form once a year.
This paperwork asks for important information to help us talk with you. It asks for your address, phone number, and the language you prefer to speak.
The paperwork lets us know we have your permission to treat you. You can also give us permission to talk with other people or organizations about your care.
Medical History
When you visit us for the first time, you will fill out a form called “Medical History.” This form asks questions about your past medical conditions, surgeries, medications, allergies, and your family’s medical history. Your answers help us give you the best care possible.
If you are 18 or older, you will fill out the “Adult Past Medical History” form. For patients under 18, a parent or guardian should fill out the “Pediatric Past Medical History” form.
Release of Information
If you want to share medical records from another clinic with your provider at Jordan Valley, you will fill out a “Release of Information” form. You will also fill out this form if you want Jordan Valley to share your medical records with someone else. You must fill out this form if you want printed copies of your medical records.
Consent for Treatment of a Minor
Children under the age of 18 must come to their Jordan Valley appointments with their parent or legal guardian. The “Consent for Treatment of a Minor” form lets parents and legal guardians give written permission for another adult to take their child to appointments at Jordan Valley.
Patient Rights & Responsibilities
Patients have rights concerning their care and treatment. We ask that you take responsibility for certain actions regarding your care. We trust our patients to provide accurate information, keep their appointments, ask providers questions, and respect other patients and staff.
Review our “Patient Rights and Responsibilities” flyer. Before visiting us, make sure you understand your responsibilities as a patient.
