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Forms and Policies

General Registration Information and Documents

To view the forms listed below, you will need to download Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.

Notice of Patient Privacy Information  

New Patient Registration Packet

Pediatric Medical History

Special Visits

Cardiac Medical History

Diabetic Patient History

Gynecology Medical History

Motor Vehicle Accident

Sports Physical Exam

Welcome to Medicare Physical Exam

Mental Health Forms/Psychometrics

Adult ADHD Self-Report Scale

Copeland Symptom Checklist


Mood Disorders Questionnaire

The Sheehan Patient-Related Anxiety Scale

The Taylor ADD Medication Effectiveness Report

Wender Utah Rating Scale

Family Health Associates

Please print and fill out forms then bring into the clinic or mail them to us. 

New Patient Registration Packet (Ages 18 and older)

New Patient Registration Packet (Age 0-17 years old)

Patient Info Sheets (New patient and annually) 

Medical Records Request forms

I want records FROM Family Health Associates to go to another clinic (Please click on the clinic where you are currently a patient):

Send records from FHA

I want records from another clinic to be sent TO High Lakes (Please click on the clinic that you would like the charts sent to):

Send records to FHA

Gynecology Forms

(Please download all three forms)

New Patient Registration (Do not fill out medical history portion of this form)

Patient Medical History-  Dr. Birschbach

Patient Review of Symptoms- Dr. Birschbach