Forms

Below you’ll find forms that are needed by our office to disclose personal information and disclose or transfer medical records. You’ll also find forms that your provider may have asked you to complete at your next appointment. If you have been asked to complete the form before your next appointment, please remember to print the form at home and arrive to your scheduled appointment early to allow sufficient time to complete the form.

Please take the time to carefully read the instructions on the forms before completing.

  • C1 - Communicate Information Verbally

    This form is used to authorize the release of your medical records (verbally) to a designated party.
    Section 1 – Patient Information
    Section 2 – The patient delegate.
    Complete all sections and sign.

  • T2 - Transfer Medical Records TO West Carleton FHT

    This form is partially completed to authorize the release of your medical records to WCFHT.

    Section 1 – Patient Information
    Section 2 – The location of the records (usually your previous physician).

    Complete all sections and sign.

  • T3 - Transfer Medical Records FROM West Carleton FHT

    This form is used to authorize the release of your medical records from WCFHT to a third party.

    Section 1 – Patient Information
    Section 3 – Who they are to be released to.

    Complete all sections and sign.

  • D5 - Disclose Medical Records TO West Carleton FHT

    This form is used to authorize the release of your medical records from a designated third party (such as another health facility).
    Section 1 – Patient Information
    Section 2 – Records Released From
    Complete all sections and sign
  • D6 - Disclose Medical Records FROM West Carleton FHT

    This form is used to authorize the release of your medical records to a designated third party (such as an Insurance Company).

    Section 1 – Patient Information
    Section 3 – Records Released to

    Complete all sections and sign.

  • Patient Health Questionnaire (PHQ-9)

    This form is used to assess changes in anxiety and depression. If you have been asked by your provider to complete this form, please print a copy at home and complete just prior to your next appointment. Or, you may arrive 15 minutes early to your scheduled appointment to allow sufficient time to complete the form at our clinic.

  • The Generalized Anxiety Disorder 7-Item Scale (GAD-7)

    This form is used to assess changes in anxiety. If you have been asked by your provider to complete this form, please print a copy at home and complete just prior to your next appointment. Or, you may arrive 15 minutes early to your scheduled appointment to allow sufficient time to complete the form at our clinic.

  • Edinburgh Postnatal Depression Scale (EPDS)

    This form is used to assess post-partum depression. If you have been asked by your provider to complete this form, please print a copy at home and complete just prior to your next appointment. Or, you may arrive 15 minutes early to your scheduled appointment to allow sufficient time to complete the form at our clinic.

  • Brief Pain Inventory

    This form is used to assess changes in chronic pain. If you have been asked by your provider to complete this form, please print a copy at home and complete just prior to your next appointment. Or, you may arrive 15 minutes early to your scheduled appointment to allow sufficient time to complete the form at our clinic.