Swofford & Halma Clinic

Swofford Clinic Inc is a Family Doctor located in Sunnyside, Washington. A family doctor is a general practitioner who treats most family members from children to adults


509-837-3933
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    • New Patient
    • Family Medicine
    • CDL Certification
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    • Obstetrics
      • Ultrasound
    • Lab
    • IDEAL Protein
    • Chronic Care Management
    • Sliding Fee Discount Program
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New Patient

Download New Patient Form

or fill the form below


Patient's Name / Nombre del paceinte*
MM slash DD slash YYYY
Is there anyone in your immediate family who is a patient with our clinic? / Hay alguien en su familia immediata que sea paciente con nuestra clinica?

*IT IS IMPORTANT THAT YOU BE AWARE THAT OUR PROVIDERS DO NOT PROVIDE PAIN MANAGEMENT TO PATIENTS / ES IMPORTANTE QUE USTED ESTE ENTERADO QUE NUESTROS PROVEEDORES NO MANEJAN DOLOR CHRONICO EN LOS PACIENTES*

Preference of doctor / La preferencia del medico?
I Certify*

AUTHORATION TO RELEASE HEALTHCARE INFORMATION

I HEREBY REQUEST AND AUTHORIZE THE FOLLOWING RELEASE OF INFORMATION
INFORMATION RELEASED TO:
Swofford and Halma Clinic, Inc.
2303 Reith Way
PO BOX 119
Sunnyside, WA 98944
Phone # 509-837-3933
Fax # 509-837-3885
Purpose, must check all that apply*
The following records are requested for release: Must Initial all that apply*
SIGNATURE OF PATIENT OR PATIENT'S AUTHORIZED REP.*
SIGNATURE OF WITNESS
My initials and signature below authorize the release of healthcare information relating to testing, diagnosis, and treatment for: Must initial the following:*

I understand that I do not have to sign this authorization in order to get health benefit (treatment, payment, enrollment or eligibility for benefits) except if I receive healthcare when the sole purpose of the healthcare is to create health information for a third party.

I understand that: A) I must revoke my authorization in writing and do so by completing and signing the Revocation of Authorization Form available at Swofford & Halma Clinic (SHC); B) If I revoke my authorization, it will not affect any actions already taken by SHC based upon this authorization, and C) I may bo be able to revoke this authorization if the purpose of it was to obtain insurance.

Once SHC has disclosed health information, the recipient may re-disclose it in some situations. Privacy laws may no longer protect the information. I understand that this authorization does not permit the release of information related to health care provided to me more than 90 days after the date of this authorization. This prohibition does not extend to insurance companies.

This authorization will expire 90 days from the date of signature.

*** This is not a transfer of care; patient's application is in the process of being review. ***

Signature of Patient or Patient's Authorized Rep.

Health Questionnaire

Name
What medications are you taking regularly?
List any surgeries: (example: appendix, gallbladder, hysterectomy, etc.)
List any major illnesses: (diabetes, high blood pressure, heart trouble, chroning lung problem, cancer)
List serious injuries
Vaccinations
Mother
Father
Brother(s)
Sister(s)
Children(s)
List any family members with cancer
Personal History
Healthy Habits
Obstetrical History (women only)

Call Us Today

509-837-3933

FAX: 509-837-3885

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