Forms

WATCH THIS VIDEO ON HOW TO FILL OUT NEW PATIENT PAPERWORK

Please use this link for New MHW Patient Info and Registration Paperwork.

If this link is temporarily unavailable then please use this paper copy version:
Paper Version of New Patient Paperwork.

If we need past medical information from your previous medical providers, please fill out the Release of Medical Information Form HERE and send it to your previous medical provider or give it to one of our providers.

Our HIPAA Authorization Form allows family, friends or other medical team members to discuss your protected health care information.

A copy of the MHW privacy and policy statements can be found here.
Refund/Return and Delivery Methods can be found here.

**We may decline to renew any controlled substances at your first appointment as that is our clinic policy.**

If you are in need of controlled substances and we agree to prescribe to you, you will be asked to review and sign this form. MHW Controlled Substance Agreement.

ALL OHP/HealthShare/CareOregon patients requiring chronic pain medication will be enrolled into the Quest Integrative WISH Program.

All of our providers like to limit the use of opioid pain medication and benzodiazepines due to the overwhelmingly negative side effects of long term use.

Benzodiazepines may increase the chance of dementia/alzheimer’s.

Opioid Addiction Statistics

CAHPS Clinician Survey Results – Patient Satisfaction & Access To Care Survey

MERRITT HEALTH Survey Results

 

Wellness & Weight Management Course Form

2023 Wellness & Weight Management

This highly popular class is only offered 2x per year, and will fill up fast. Classes are billed to your insurance. Family members/friends can join too. From a previous participant: “This course was more than worth my time and money. Lindsey is a personable and engaging presenter. I learned so much about nutrition and the multifactorial challenges of my weight struggles, and the realistic steps to take for living a consistently healthy lifestyle.

IUD Consent Form

IUD Consent
Implantable Contraceptive CIIC

Advance Directive, POLST, End of Life Planning

About POLST and Advance Directives
Advance Directive Form
Five Wishes sample

Useful Patient Symptom Forms – Institute For Functional Medicine

MHW Hormone Questionnaire
MHW Digestive (gut) Wellness Questionnaire
Toxicity Questionnaire

Useful Patient Dietary Info

MHW Phased Diet
Diet Guide MHW
MHW Food List
MHW Vegetables

Useful Patient Info

Multnomah County Syringe Disposal Information

 

IF: 45 FAQ

FAQ Intermittent Fasting (IF) 45 Course