Forms
Forms

Download Forms

Please download the applicable forms using the links below. Fax completed forms to 855-847-9876 or bring them with you to your appointment.

ADULT PATIENT FORMS

PDF download includes the following forms: Registration Information, Authorization for Release of Information, Eunoia Financial Policy, Privacy Policy and Acknowledgements.

CHILD PATIENT FORMS

PDF download includes the following forms: Registration Information, Authorization for Release of Information, Consent for Treatment of a Minor, Eunoia Financial Policy, Privacy Policy and Acknowledgements.

VULNERABLE ADULT PATIENT FORMS

PDF download includes the following forms: Registration Information, Authorization for Release of Information, Consent for Treatment of a Vulnerable Adult, Eunoia Financial Policy, Privacy Policy and Acknowledgements.

REFERRAL FORM (ALL OFFICES)

PDF download includes a Referral Form for all offices. Please mail completed form to Eunoia Family Resource Center, 1420 N. State Street, Fairmont, MN 56031; or fax to 855-847-9876.