For your convenience, we have made frequently used patient forms available online. Completed forms can be mailed to:

Mid Dakota Clinic PrimeCare
Attn: Front Office Supervisor
PO Box 5538
Bismarck, ND 58506-5538

You may also drop completed forms off at the Main Clinic at 401 N. 9th St. or fax them to (701) 530-5934.

All forms are in Adobe Acrobat and require the Adobe Reader which can be downloaded here.


Authorization to Treat a Minor
A Parent or Legal Guardian must give informed consent for Mid Dakota Clinic to examine and treat a minor. If you cannot attend the appointment, then: (a) you may appoint another responsible adult to bring the child to the appointment; or (b) if your child is 15 or older, your child may come to the appointment without you.  You must, however, complete and sign the Authorization to Treat a Minor form and return it to the Clinic on or before the scheduled appointment. You must also be available by phone, in case the provider needs to contact you.
 
Patient and Family Advisor Application

Release of Patient Information

Release of Information to Family

Sports Physical Form (NDHSAA)
Most sports programs follow the guidelines of the North Dakota High School Activities Association (NDHSAA) which requires a physical examination be completed on or after April 15 to be valid for participation the following school year. A parent/guardian must accompany children ages 14 and younger.