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.

Other Forms

WWMC AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS (Transfer of medical records TO or FROM Western Wayne Medical)

WWMC AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

WWMC Disclosures and Consents, Financial Agreement

WWMC Consent For Treat Minor

WWMC Patient Complaint Form

WWMC Flu Vaccine Consent Form

WWMC Return to Work Form

Policies and Practices

WWMC Notice of Patient Rights and Responsibilities

WWMC Notice of Privacy Practices

WWMC Controlled Substance Policy

 

Wayne County Public School Athletic Participation Form

Wayne County Public School Athletic Health 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.