PCW Program Forms
Clinic & Class Attendance Policy. To be signed and turned in.
Body Mass Index chart based on height and weight.
Client Commitment Form
Commit to the services of Physician’s Choice Wellness. Please read, sign and date.
Electronic Statement Authorization
Authorize PCW to discontinue paper statements in exchange for email statements.
This form is part of the Application Enrollment. Please print, read and sign.
Protected Health Information Access Form
Initial Screening Physical Questionnaire
Our program initial screening questionnaire.
Meal Replacement – Snack Options
All of our meal replacement beverage flavors, snacks and bars!
Patient Consent Form
Patient Consent for Use and Disclosure of Protected Health Information
Enrollment Application for the New Direction VLCD and New Direction LCD
Protected Health Information Policy
PCW’s policy on how your health information will be used.
Self Billing Form- Illinois
Use this form if you are self billing your insurance company.
SMS Texting Consent
This form is to give consent for PCW to text appointment reminders.
Treatment Consent Form
Authorization for examination and treatment. Please sign and date.