Patient Forms

Sometimes we need extra information to coordinate your care — whether it’s for an MRI, a medication request, or updating your health history. Use the forms below to submit details quickly and securely, so we can process your request without delay.

Prior Authorization Request

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MRI
CT (CAT) Scan
GLP-1 (Ozempic/Wegovy, Mounjaro/Zepbound, etc)

Getting Started Forms

Complete these forms to help us learn about your health history, lifestyle, and goals before your first visit.
New Patient Intake Form:
Medical Record Release Form:
Insurance Information:

Health Forms & Screenings

Please only complete these forms if requested by our office before your annual physical or a specific visit. They help us better understand your symptoms, risks, and current health needs.
Lifestyle Intake Form:
Pittsburgh Sleep Quality Index:
STOP-BANG Score for Obstructive Sleep Apnea:

At Direct Primary Care of West Michigan, you are not just a patient, you are part of our family.

Contact DPCWM to set up a free meet & greet.