NOTE: New patients under 18 years of age must be accompanied by a parent or guardian at their first visit.
When filling out forms, are you wondering why Grace Health is asking personal questions? Knowing where you come from and what makes you the person you are today, such as race, ethnicity gender identity, etc. helps us to understand our community’s diverse population and how we can better serve your individual needs. By having this information, we can incorporate quality and access to care.
New Patient Forms
General Forms (Formularios Generales)
Advance Directive
Acknowledgement of Receipt of Notice of Privacy Practices
Privacy Practices
Reconocimiento de haber Recibido el Aviso de Prácticas de Privacidad
Prácticas de Privacidad
Authorization for Release of Medical Information
Autorización para la divulgación de información médica
Healthy Michigan Plan Health Risk Assessment
Medical Care Authorization and Consent for Treatment
Autorización de atención médica y consentimiento para el tratamiento
Medicare Wellness Visit Assessment
Sliding Fee Discount Application
Aplicación para el Programa de Descuento
Pediatric Forms (Formularios de Pediatría)
Pediatric Demographics
Datos Demográficos de Pediatría
Patient Eligibility Screening Record – Vaccines for Children Program
Registro de Revisión de Elegibilidad del Paciente – Programa de Vacunas para Niños
Adult Forms (Formularios de Adultos)
Adult Demographics
Datos Demográficos del Adulto
Dental Forms
Dental Health History
Portable Dental Services 2024-2025
Servicio Dental Móvil 2024-2025
Behavioral Health
Behavioral Health Counseling Services Packet
Student Health Center Forms
Student Health Center Forms Packet
