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New Patient Paperwork

Please print and bring completed forms to your appointment.

Por favor, imprima y llene los siguientes formularios para traerlos a su visita.

Form

New Patient Registration Form

New Patient Registration Form >
form

Patient History Form

Patient History Form >
Form

Authorization for Use and Disclosure of PHI

Authorization for Use/Disclosure of PHI >
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Notice of Privacy Practices

Notice of Privacy Practices >
Form

Sliding Fee Scale Application

Sliding Fee Scale Application >
Form

La Comunidad Beneficia a la Aplicación

La Comunidad Beneficia a la Aplicación >
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Notificacion de Practicas de Privacidad

Notificacion de Practicas de Privacidad >
Contact Us

820 East 17th Street

Cheyenne, WY 82001

Phone: 307-632-2434

Fax: 307-634-7691

Email: uwfmcb@uwyo.edu

1000 E. University Ave. Laramie, WY 82071
UW Operators (307) 766-1121 | Contact Us | Download Adobe Reader

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