Clinic Forms

The following forms can be printed and completed prior to visiting a Mercy Clinic.  Forms will not be accepted via fax or email. 

Adult Forms

1. Patient Information Form-English  OR   Patient Information Form-Spanish
2. Patient Medical History Form
3. Authorization for Release of Medical Information
4. Confidential Alternative Communications Request
5. Patient Information-Financial Consent - English  OR  Patient Information-Financial Consent - Spanish
6. Notice of Privacy Practices - English  OR  Notice of Privacy Practices - Spanish
7. Acknowledgement of Notice of Privacy Practice

Pediatric Forms

• Pediatric Patient Information Form
• Foster Child Patient Information Form