Patient Forms

Prior to your first appointment, you may be asked to complete a few forms to provide us with your medical history and other information. These forms can be printed and filled out, then mailed back to us or brought with you to your first appointment.

If your appointment is for medical services, please fill out forms 1 and 2. If your appointment is for psychiatric services, please fill out form 3. 

  1. Medical Patient Information Form
  2. Medical History Form - Adult
  3. Medical History Form - Child
  4. Psychiatric Health History Form

Telehealth Consent Form

Please click here to complete our online Telehealth Consent form so that we can provide treatment through phone or our online video platform if needed.

Patient Records Request Form

Please click here to download a patient records request form. Once completed, this form can be dropped off at any of our locations, faxed to 515-883-2683 or mailed to UCS Healthcare, ATTN: Patient Records Request, 1300 Woodland Avenue, West Des Moines, IA 50265.