Forms

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

If this link is temporarily unavailable then please use this paper copy version:

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 bring it to the first office visit.

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 FamilyCare 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

 

IUD Consent Form

IUD Consent MHW

Implantable Implanon Consent MHW

 

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

Short-Inflammatory-Bowel-Disease-IBD-Questionnaire_BRFINAL_v2

Toxin-Exposure-Questionnaire_BRFINAL_v2

Thyroid-Screening-Questionnaire_BRFINAL_v2

HPA-Axis-Questionnaire_BRFINAL

Candida-Screening-Questionnaire_BRFINAL_v2

Functional-Medicine-All Body Symptom Questionnaire

 

Useful Patient Dietary Info

MHW Phased Diet

Diet Guide MHW

MHW Food List

MHW Vegetables

Anti-Candida-Food-Plan_BRFINAL