Patient Guide

Click here to view the Utica Park Clinic Patient Guide.

Forms

Get a start on your visit by completing the necessary paperwork at a time that is more convenient for you before you arrive.  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.

Before your first visit to Utica Park Clinic, please complete one of the following two appropriate forms:

• New Patient Registration and History Form – Adult
• New Patient Registration and History Form – Pediatrics

Other forms:

• 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 Two-Minute Survey - Primary Care 
• New Patient Two-Minute Survey - Specialists 
• 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

authorization_for_disclosure.pdf

Health Risk Assessment 11 0103.pdf

New Patient Survey PCP 12 0301.pdf

New Patient Survey Specialist 12 0306.pdf

New Patient History and Regist Adult 12 0804.pdf

New Patient History and Regist Peds 12 0804.pdf

New Patient History and Regist Peds 12 0921 leaf logo.pdf