Patient Portal
TeleHealth
Self-Scheduling
Medical File Share

PATIENT FORMS

HOW TO USE THESE FORMS

  1. Click form to open
  2. Fill information with a PDF reader on your desktop or mobile device
  3. Save completed form 
  4. Upload form to your provider’s office using Medical File Share.
  • You may alternatively print and fill out the form to bring into the office.

    New patients must submit a photo or copy of driver’s license and insurance card, front & back, when submitting a New Patient Request form.

ENGLISH FORMS

New Patient Request Form

Western Colorado Pediatrics New Patient Request Packet

HIPAA Disclosure Authorization

New Insurance Information

Records Release Authorization (ROI)

Adult Proxy Release Form: Patient Portal

Receipt of HIPAA Policy

Payment Policy

Parental Consent for Adult Child

Adult Proxy Registration Instructions: Patient Portal

Colorado Immunization Information System (CIIS) Notice

Español FORMS

Descripción General De Paciente Para Western Colorado Pediatrics

(Western Colorado Pediatrics: Clinic Overview – Spanish)

Guía De Familias Separadas Y Divorciadas

(Separated/Divorced Families Guide – Spanish)

Instrucciones de Registro Como Apoderado Para Niños

(Minor Proxy Registration Instructions: Patient Portal – Spanish)

Menor Proxy Forma De Liberación

(Minor Proxy Release Form: Patient Portal – Spanish)

Adulto Proxy Forma De Liberación

(Adult Proxy Release Form: Patient Portal – Spanish)

PEDIATRIC FORMS

Western Colorado Pediatrics New Patient Request Packet

Western Colorado Pediatrics: New Patient Request Form

Western Colorado Pediatrics:
Social Family History Intake

Parental Consent for Adult Child

Western Colorado Pediatrics: Clinic Overview

Separated/Divorced Families Guide- English

Minor Proxy Registration Instructions- English: Patient Portal

Minor Proxy Release Form- English:
Patient Portal