New patient registration
Please use our Online New Patient registration form
please print and fill information using the links below and mail, email, fax or bring to our office.
- Step 1: WWMC New Patient registration form
- Step 2: WWMC Adult Medical History
- Step 3: WWMC Disclosures and Consents, Financial Agreement
WWMC AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS (Transfer of medical records TO or FROM Western Wayne Medical)
Policies and Practices
Wayne County Public School Athletic Participation Form
Western Wayne’s policy related to completing above WCPS forms:
Patients requiring a form completed by our office for school, camp, sports, pre-school, medication administration forms, or any other form that requires a physician’s signature, if brought in conjunction with your child’s well/physical exam visit, the office will complete the form at no additional cost to the parent. Please ensure that you complete all components of that form prior to your child’s arrival at our office. Western Wayne encourages parents to bring the form with them as we may not have the most up to date required form for your child at hand.
Should the necessary forms not be presented by the parent at the time of your child’s well/ physical exam visit and it is brought in or mailed to our office for completion after their well/physical exam visit, you will be subjected to a $5.00 administrative fee for each form/each child that will be due upon Western Wayne’s completion of that form. If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that this $5.00 fee is not covered by your medical insurance policy.