Forms

If you would like to fill out your patient forms ahead of time, please print the appropriate packet:

Certification & Renewals

Miscellaneous forms

Pain Log Track your pain or other symptoms with two/three entries per day for two weeks.

Patient Change Form This form should be used by patients to submit a legal name change, change of address, remove/add/change a caregiver or to request a replacement card.

Caregiver Change Form This form should be used by caregivers to submit a legal name change, change of address or to request a replacement caregiver card.

Medical Records Release Form This gives us permission to obtain your medical records. Please fill out and return to us with your doctor's FAX AND PHONE number. It may be faster to obtain your records yourself and bring them with you to your appointment. If you choose, you may fax them to (269) 382-1197, or mail them to: Michigan Holistic Health, 500 Crosstown Pkwy, Kalamazoo, MI 49008.