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                      Patient Forms


                      Advance Directives

                      Each individual has the right to direct his or her own care. Current information about Advanced Directives and Indiana state forms can be found on the Indiana State Department of Health website.

                      Forms included, but not limited to, include:

                      • Health Care Representative Appointment
                      • Life Prolonging Procedures Declaration
                      • Living Will Declaration (English and Spanish versions)
                      • Out-of-hospital Do Not Resuscitate Declaration and Order

                      Learn more at the Indiana State Department of Health website

                      Parental Consent

                      If you're traveling and have to leave your children in the care of someone else, be sure they're protected. Always leave written authorization so your children can receive medical treatment, if needed.

                      Simply download the form below, fill it out and leave it with your children's caregiver. An authorized form is valid for one year following the signature date unless the form has been withdrawn with written consent.

                      Delegation of Authority to Treat Minors Consent Form (PDF).
                      Instructions for the completion of the Delegation of Authority to Treat Minors Consent Form (PDF).

                      Patient Registration and Information Form

                      • Authorization for Release of Health Information

                      Warsaw Patients

                      Download the new patient packet:

                      • Patient Consent for E-Prescribing
                      • Information Disclosure Authorization
                      • New Patient Medical History Questionnaire
                      • Patient Registration Form
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                      • Race and Ethnicity Form
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                      Lutheran Health Physicians

                      • 7916 W. Jefferson Blvd.
                      • Fort Wayne, IN 46804

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                      Copyright ©2025. All rights reserved.

                      A medical group of AllianceHealth Oklahoma®

                      Services

                      • Anticoagulation Clinic
                      • Bariatric Surgery
                      • Bone Health
                      • Breast Cancer Surgery
                      • Business Health Services (RediMed)
                      • Endocrinology
                      • Family Medicine
                      • Gastroenterology
                      • General Surgery
                      • Heart Care
                      • Infectious Disease Care
                      • Internal Medicine
                      • Neurointerventional Surgery
                      • Neurology
                      • Neurosurgery
                      • OB/GYN
                      • Occupational Health Services (MedStat)
                      • Ophthalmology
                      • Pediatrics
                      • Podiatry
                      • Primary Care
                      • Pulmonology
                      • Rheumatology
                      • Sports Medicine
                      • Trauma Surgery
                      • Urgent Care (MedStat and RediMed)
                      • Urology
                      • Wound Care

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