For your convenience, you can complete the forms below by downloading, printing, filling them out and bringing them with you to your first visit.
- Assignment of benefits form
- Acknowledgement of receipt of notice of privacy practices
- View our notice of privacy practices
- Medical history form
- Review of symptoms form
Release of information
In order for WVCI to release a patient’s confidential medical records to a third party, the authorization form below must be completed and signed by the patient. The authorization form can be mailed, hand-delivered, or faxed to either location listed on the form (Eugene or Springfield), to the attention of: Medical Records Department.
Patient binder forms
You will receive a new patient binder at your first appointment. If you need additional pages for the My Health Care or My Journal section, we have provided blank forms for your convenience, here.
- My calendar
- My appointment questions
- My treatment history
- My prescriptions
- My over-the-counter medications
- My allergies/intolerances and contraindications
- My notes
- My journal
Gynecologic oncology forms
- GYN oncology patient pre-visit medical history form
- Pre-operative instructions
- Pre-operative bowel prep instructions
- What to expect in the hospital after surgery
- Care guidelines after surgery