Here at Midwest Health Center we offer the convenience of printing out our new patient form from your home or office. Please click on the link below to print it out. This form is our Patient Health Questionnaire which asks for your demographic information and details about your symptoms that you are currently having. It also is an inquiry of the medications that you are currently taking. Please read this form thoroughly and have it filled out and signed prior to your appointment. Also, please remember to bring this form along with your driver’s license and insurance cards to our office.

Please download and fill out the following form and bring them in with you to your appointment.

Download Form

Thank You!

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.
    For questions or more information about your right to a Good Faith Estimate, visit