Forms

  
New Patient Forms (4) come as a complete set, and includes the Patient Registration, Consent To Medical Care, Patient History Questionnaire, and HIPAA Consent Forms. Please bring completed forms to your first appointment.   The Patient Registration Form asks for your contact information, employer, and insurance information. If you have address, insurance, or telephone number changes after submitting your information, please make sure to update our office directly.
       
The Consent To Medical Care and Financial Responsibility Form asks that you agree to being examined and treated by our doctors, and explains your financial obligations for care provided by our office.   Our Patient History Questionnaire helps your doctor get a better understanding of your current and past health status. Please be as thorough as possible in listing information on this form.
       
Our HIPAA Privacy Policy Consent Form is required under federal law, and indicates your understanding and acceptance of our Privacy Policy. If you have not read the Privacy Policy, a copy is provided on this website.   Our Release Of Records Form can be used to have your medical records from a previous physician sent to our office, or can ask this office to release records to others.
       
The Ohio Department of Job and Family Services Medical Form is often required for children who will be attending daycare or similar facilities. If your child's doctor does not have an up-to-date vaccine administration record, please bring one to your child's exam.   The Ohio Department of Job and Family Services Medication Administration Form is used for children attending daycare (or similar facilities) if a prescription medication, or certain over-the-counter medications, will be administered by daycare staff.
       
Student athletes will need the Sports Physical Form that is required by the local schools for participation in organized sports or cheerleading. Get a copy here, and complete the history side prior to your child's exam.   The Certification of Health Care Provider is an optional form that an employer may use if it chooses to require certification from a health care provider that a serious health condition requiring leave under the Family and Medical Leave Act (FMLA) exists.
       
For individuals in need, the BMV makes available special license plates which allow holders to use specially designated parking spaces. This License Plate Form is available here, but it will need to be completed by you and your doctor.   For individuals in need, the BMV makes available parking placards which allow holders to use specially designated parking spaces. This Parking Placard Form is available here, but it will need to be completed by you and your doctor.
       
Boy Scouts Of America Class 1 & 2 Physical Form can be downloaded and the patient portion should be filled in prior to your exam. Bring the form to your physical for your doctor to complete and sign.   Boy Scouts Of America Class 3 Physical Form can be downloaded and the patient portion should be filled in prior to your exam. Bring the form to your physical for your doctor to complete and sign.
       
Minor (Student) Work Permits are frequent reasons for adolescent physical exams. Here is the medical form that may be required before your student can become employed, as well as the pre-application to be completed and taken to your child's school.   DNR-CC stands for Do Not Resuscitate - Comfort Care only. In specific instances, resuscitation efforts may not be appropriate at the end of life. For the convenience of our patients, this form is available to review, and to take to your physician for a discussion of your wishes.
       
Advance Directives can help make your wishes known to family and health care personnel should you become incapacitated. Here is a package of information, including Ohio Living Will and Durable Power of Attorney for Healthcare forms from http://www.ohpco.org.   Commercial Driver's License Examination forms and instructions are available for truck drivers and others who are required by the DOT to carry this certification.

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