New Patient Information and Patient Forms

Appointment Checklist

  • Please bring in a copy of the patients insurance card and the drivers license of the primary cardholder.
  • Legal Guardians should bring proof of guardianship.
  • If someone other than the parent or legal guardian brings in a child under the age of 18, they should have a written note of consent to provide care for that child.
  • A patient who is new to our practice should arrive 15 minutes prior to their appointment time to complete paperwork. You may also print the paperwork from this site and bring it with you to the appointment.

Read the HIPAA Policy pdficon_small

Yearly Demographic Update Form pdficon_small

Consent to Share Information (for patients over 18yrs) pdficon_small

Forms for New Patients -- Form Bundle pdficon_small   This bundle contains:

  • Yearly Family Demographic Form
  • PHC Consent form:
    • Patient Consent for use and Disclosure of Protected Health Information
    • Acknowledgment of Review of Notice of Privacy Practices
    • Acknowledgment of Review of Michigan Laws Related to Right of a Minor
    • Medical Consent for Proxy of Minor Children
    • Medical Consent to Testing
  • PHC Financial Policies
  • PHC Health History

Other Health Forms 

42141 Mound Road  -  Sterling Heights, MI 48314  -  phone: 586-254-7593  -  fax: 586-254-7834