Specialty Services Forms
If you are scheduled for any of the following specialized services, click on the name to access a pdf that you can print, complete, and bring to your visit. If you are a NEW patient to our center, please also log onto our secure portal and complete the registration form and adult personal health history forms.
• Mental Health Counseling with one of our counselors.
• Nutritional Counseling with our dietician.
• Massage Therapy with one of our massage therapists.
• Acupuncture or Chinese Herbal Medicine Consultation with Gina Butler.
Registration and Health History Forms
If you are a new patient with Women's Wellness Center, please fill out a registration form via our secure portal.* Once you are registered in the portal, you will be directed to the appropriate health history forms.
*If you experience difficulty with the online registration
Please download the appropriate forms below, print and fill them out, then fax to 573.441.9355, or mail to Women's Wellness Center, 1705 E Broadway, Suite 300, Columbia, MO 65201. We'd like to receive these forms at least 2 business days before your appointment, earlier if possible.
• Registration Form
• Adult Personal Health History Form (if patient is 18 or older)
• Pediatric/Adolescent Personal Health History Form (if patient is under 18)
Other Forms
• Durable Power of Attorney for Health Care/ Health Care Directive: These documents are optional and are not required for you to receive care at Women’s Wellness Center. They are provided solely to make you aware of the options you have regarding your health care should you become incapacitated.
• Records Release TO Women's Wellness Center This form allows you to request that records be sent from another provider to Women's Wellness Center. Please be sure to send this request form to the provider from whom you are requesting records.
• Records Release FROM Women's Wellness Center This form is to request that records from Women's Wellness Center be sent to another provider.
