Patient Guide

Click here to view the Utica Park Clinic Patient Guide.

Get a start on your visit by filling out these forms ahead of time. To use, simply click on the links below to view the PDF document, print the form, fill it out, and bring it with you to your appointment.

• Authorization for Emergency Care to Minors
• Authorization for use or disclosure of protected health information (Medical Records Release)
• Health Risk Assessment for Medicare Patients 
• Living Will - Advance Directive
• New Patient Registration Form
• New Patient Two-Minute Survey 
• Patient Personal History Form - Adults 
• Patient Personal History Form - Pediatrics
• Pre-Participation Physical Form

The forms are in PDF format. If you do not have a PDF reader installed, click here to download the free Adobe PDF Reader.

Image: 

File: 

PHY_2.0.10_Attachment_A.pdf

minor_care_authorization.pdf

ok_advance_directive.pdf

new_patient_registration.pdf

New Patient Survey 11 0303.pdf

Ped History form.pdf

authorization_for_disclosure.pdf

History Form Adult 12 0130.pdf

Health Risk Assessment 11 0103.pdf