First, and most importantly, we would like to welcome you to Midlands Family Medicine.
We appreciate the opportunity to help you and your family attain and maintain an active, healthy lifestyle.
So that we can serve you more quickly at your initial visit, please fill out the forms noted below prior to your visit.
These forms can be filled out online (Adobe Reader version 8 or higher required) and printed off. The forms can also be printed off and filled out by hand should you prefer to do so. Please bring the completed forms with you to your first clinic visit or mail them to us prior to your scheduled visit.
Again, we would like to welcome you to our home!
Please note that none of the information entered on these forms will be saved.
***Please print a copy of each form after it is completed to bring with you to your visit.
We must have both forms signed prior to seeing you.
To return to this page from each form, be sure to use the “Back” button in your browser window, do not “Close” the window as it will close your internet session.
Adobe Reader version 8 or newer required to open forms below.
Policies below for information purposes only.
You may print these out for your records.
To return to this page from each form, be sure to use the “Back” button in your browser window, do not “Close” the window
Records Release Form (for all patients)
Please fill out this form so what we may obtain your medical records from your previous physician
New Patient Information/Forms
Providing Inpatient and Outpatient Pediatric, Adult, Geriatric, Obstetrics, and Endoscopic care for you and your family
Midlands Family Medicine
611 West Francis St Suite 100
North Platte, NE 69101