Patient Forms

• Durable power of attorney for healthcare
• Healthcare directive

• Email Consent
• Notice of Privacy Practices Acknowledgment​
• Patient Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity
• Patient Authorization to Disclose, Release and/or Obtain Protected Health Information
• Patient Authorization to Leave Personal Health Information by Alternate Means
• Patient Authorization to Use and Disclose Protected Health Information for Publication
• Patient Authorization to Use or Disclose Photography/Video
• Request to Consider Additional Privacy Protection for Protected Health Information
• Request for Correction or Amendment of the Medical Record
• Request to Restrict Disclosure of Healthcare Items or Services to Health Plans When Patients Self-Pay Out of Pocket

• New patient registration form

• New patient history form

• Rheumatology Questionnaire
• Care Team Contact Information
• Race and Ethnicity Data Collection
• New Patient Registration Information

• Sterilization consent

• Dermatology intake form

• Quick Dash Questionnaire
• Hand Foot and Ankle Institute Questionnaire
• Foot and Ankle Ability Measure

• Male fertility new patient history
• Endocrine new patient history
• Female-male couple fertility new patient history
• Female single or same-sex couple fertility new patient history
• Transgender new patient history

• Alcohol and substance abuse agreement
• Dental clearance for kidney pre-transplant evaluation
• Kidney pre-transplant patient agreement
• Kidney transplant demographic information
• Kidney transplant recipient selection criteria
• Patient acknowledgement for kidney, pancreas or kidney-pancreas transplant
• Transplant services blood pressure record

• Welcome letter
• Patient form
• Care partner form

UW Psychiatry Patient Documents for Telemedicine Visits

New Patient Forms – Outpatient Psychiatry Clinic
Provided are links to forms for patients who are seeing a provider at the UW Outpatient Psychiatry Clinic. Please complete these forms and have them handy to review with your provider.

• New Patient Form – OPC
• OPC Initial Symptom Review
• Mood Disorder Questionnaire (MDQ)
• Drug Abuse Screening Tests
• Audit-C Questionnaire
• PCL-S PTSD Checklist
• PC-PTSD-5 Questionnaire
• Patient Health Questionnaire 9 (PHQ-9)
• Generalized Anxiety Disorder (GAD-7)
• ROS - Review of Symptoms
• Safety Plan Template

Telehealth Patient Info Sheet and Zoom User Guide
Provided are links to the forms for you to review prior to your initial appointment.

• Telemedicine for your Mental Health Care
• Patient – Zoom User Guide

Questionnaires
Provided are links to the forms that you may need for your appointment. Please complete these forms and have them handy to discuss with your provider.

• PHQ-9
• GAD-7
• Safety Plan Template

• Outpatient MRI screening | Arabic | Chinese | Japanese | Korean | Russian | Somali | Spanish | Tigrinya | Vietnamese
• CT contrast injection patient questionnaire | Arabic | Chinese | Japanese | Korean | Russian | Spanish | Vietnamese
• Cardiac perfusion scan questionnaire

• Sleep Clinic Patient Questionnaire

• Concussion Assessment Tool: Baseline Test
• Concussion Assessment Tool: After Injury

Advanced Manual Therapy and Sports Rehabilitation Clinic

• Questionnaire - Outpatient Physical Therapy

• Patient Medication History Form UH2301
• Evaluation for Metabolic Surgery to Manage Obesity Patient Questionnaire UH3008
• Questionnaire on Eating and Weight Patterns UH3305
• New Patient Evaluation UH3850

• Breast Health Center Patient Intake
• Obstetrics/Gynecology New Patient Intake
• Vulvovaginal Specialty Clinic Intake
• Women's Health Preventative Health Visit - Established Patient
• Midwives Clinic at Northwest Outpatient Medical Center