Save time! Fill out these forms before your appointment.

To complete your paperwork, read the HIPAA notice, then download and print the PDF Patient Data Form, fill out and sign it, and bring it to your appointment.

The Patient Data Form below is for these health centers:

  1. Ann Arbor
  2. Ann Arbor West
  3. Benton Harbor
  4. Burton
  5. Detroit
  6. Ferndale
  7. Flint
  8. Jackson
  9. Kalamazoo
  10. Lansing
  11. Livonia
  12. Saginaw
  13. Warren

If your health center is not listed above, access the forms for our West and North Region.

Note: If your appointment is for abortion services, please get the appropriate forms on the Abortion Services page.

1. HIPAA Notice

Read this notice of health information privacy practices (optional). You can also read the HIPAA notice in Spanish.

Read the HIPAA Notice

2. Patient Data Form

Select, download, print, and fill out the form Patient Data Form.

Prefer Spanish? Get the Spanish Patient Data form.

Get the Patient Data Form (PDF)