Clinic Forms

The following forms can be printed and completed prior to visiting a Mercy Clinic. Please do not submit forms via fax or email. 

Adult Forms

• Patient Information Form-English
• Patient Information Form-Spanish
• Patient Medical History Form
• Authorization for Release of Medical Information
• Confidential Alternative Communications Request
• Patient Information-Financial Consent - English
• Patient Information-Financial Consent - Spanish
• Notice of Privacy Practices - English
• Notice of Privacy Practices - Spanish
• Acknowledgement of Notice of Privacy Practice

Pediatric Forms

• Pediatric Patient Information Form
• Foster Child Patient Information Form