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.
Authorization to communicate medical information (c1)
This form is used to authorize the release of information from your medical record (verbally) to a designated party. This form must be completed in order to allow us to discuss test results, appointments and other medical information with a designated party (such as a spouse, caregiver, or family member). It is sometimes referred to as a privacy directive.
transfer medical records To west carleton fht (t2)
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)
TRANSFER MEDICAL RECORDS from WEST CARLETON FHT (t3)
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 your records are to be released to.
disclose medical records to west carleton fht (d5)
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
DISCLOSE MEDICAL RECORDS from WEST CARLETON FHT (D6)
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
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.
This form is used to assess postpartum 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.
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. Under the field "study name" please include your first and last name and date of birth.
PARENT/GUARDIAN AGREEMENT FOR COUNSELLING SERVICES
This form is used to authorize a referral for a child under the age of 13 to receive mental health services. This form must be signed by both legal guardians in order for a child under the age of 13 to be eligible to receive counselling services. When one parent is absent or unable to consent, the Declaration of Custody form must be completed.
This form is used to support a referral to mental health services for a child under the age of 13 when one parent is absent or unable to consent to the referral. In circumstances where one parent is absent, this form must be completed prior to the child receiving mental health services.
A Personal Care Assistant (PCA) is an individual who attends appointments and provides assistance to a patient to help manage their medical condition. A PCA may be encouraged for patients who have mobility issues or the inability to record, comprehend, or retain all medical information relayed to them during their medical appointment.
For more information about Personal Care Assistants, click here. To authorize a PCA to communicate with our staff, an enrolment form must be completed.
