Patient forms

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

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.

Medical records release

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

For medical professionals

New patient referral form