Patient Forms

For Our NEW Patients

To provide you with the best possible care, we need the most up-to-date information about you. Please help us provide the best health care for you by completing all pages of the below forms and bring with you to your appointment. 

     1)  Patient Information Form

     2)  New Patient History Questionnaire

For Our ESTABLISHED Patients

If you are an established patient who has not visited our office within the past three months, we will need an updated Return Annual Patient Questionnaire at your next appointment.

Notice of Privacy Practices

You can view our privacy practices prior to your visit. 

Authorization To Release Medical Information

You can print, fill out, and bring in this Authorization To Release Medical Information form if you would like to forward your records elsewhere or if Ruch Clinic needs to release/receive your medical records from another facility. 

Blood Sugar Log

For our gestational diabetes patients, click here to print a Blood Sugar Log.  

A division of Women's Care Center of Memphis, MPLLC.