Call us: 541-926-4828
Mid-Willamette Family Medicine
To complete your Patient Application, please complete the following and return to our office with a valid Photo ID and Insurance Card.
*All sections are required to be completed. If a section does not apply, please indicate so on the form*
VOLUNTARY INFORMATION DISCLOSURE
This form provides voluntary consent to track demographic information used to benchmark trends in public health.
This form consents us for using and disclosing your health information for purpose of management of your health care.
AUTHORIZATION TO RELEASE MEDICAL RECORDS
This form authorizes your prior doctors to release medical records to our office