Forms

New Client Deposit Agreement Form

To use the fillable PDF form below, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. If you know how to electronically sign it, please do so. Otherwise print out the form and sign it. After completing and signing the form, please email the form or a photo of it to info@womansafehealth.com, fax to 734-477-5111 or mail to 2340 E. Stadium Blvd. Ste 8 Ann Arbor, MI 48104.

Once WomanSafeHealth has received your form and you have indicated that you prefer to use a credit card, the office staff will contact you to complete payment and set up an appointment. If you are using Paypal, or sending a check, money order, or cash with your new client deposit agreement, WomanSafeHealth will need to make sure your payment has cleared before the office staff will contact you to set up your new client appointment. If you have not heard from staff within 3 business days, please feel free to contact the office at 734-477-5100 or email us at info@womansafehealth.com.

WomanSafeHealth Herstory Form

If you have a new client appointment, please fill out as much of this form as you would like to. We will complete your health herstory together when we see you for your appointment.

To use the fillable PDF form on this page, please download and save the form to your desktop first. After saving the form, open it directly from your computer, fill it out and save your changes. Please do not fill it out from an internet tab because your changes will not save.

    After your changes are saved, you may return it to our office in one of the following ways:
  • 1) bring the completed form to your appointment as a paper copy or on a jump drive, or
  • 2) email the completed form to info@womansafehealth.com, or
  • 3) mail the completed form to 2340 E. Stadium Blvd Ste. 8 Ann Arbor, MI 48104, or
  • 4) fax the completed form to 734-477-5111

Clients Under 18 Policy

WomanSafeHealth is highly committed to protecting the privacy and confidentiality of all clients* including those less than 18 years old. Medical care or counseling that involves issues of birth control, sexually transmitted infections, pregnancy or substance abuse is kept confidential between the client and WomanSafeHealth provider as required by Michigan law.** Information about the medical care provided, including diagnoses, treatment and follow up for young clients will only be shared after written authorization from the client has been received. The fee schedule for medical care and other WomanSafeHealth services is the same for all, including clients under 18, and payment is expected at the conclusion of the appointment. We encourage all clients to make their own appointments. All clients are welcome to bring parents, friends or other support individuals to their appointments if they wish.

*WomanSafeHealth serves women, girls, trans and gender nonconforming people.
**WomanSafeHealth staff are mandated reporters when there is suspicion or evidence of child or elder abuse or neglect.

If you have any questions, please contact our office at 734-477-5100 or info@womansafehealth.com