Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Advance DirectiveAdvance directives are written instructions regarding your medical care preferences. Your family and doctors would consult your advance directives if you were ever unable to make your own health care decisions. A mental health directive is narrower in scope and pertains specifically to mental health treatment.Do you have an advance directive or a mental health directive? Yes No If you have an advance directive, may we have a copy? Yes No Copy received If you have a mental health directive, may we have a copy? Yes No Copy received Would you like to receive additional information on advance directives? Yes No Advance Directive Consent* I understand that advance directives and mental health directives are legal documents. In accepting this advance directive form, I understand that Zumbro Valley Health Center is not qualified to give legal advice and will not be held liable for decisions made in completing this document.Epidemiology Research AuthorizationEpidemiology Research Consent* Yes, I authorize Zumbro Valley Health Center and its research partners to use my medical records for research. No, I do not authorize Zumbro Valley Health Center and its research partners to use my medical records for research.
