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Patient Forms

Patient Forms for Downloading and Printing

General Forms
Ancillary Forms

General Forms

Below are the generic forms that are frequently used at our practices. If you have any questions regarding our patient forms, please feel free to contact us.

2025-2026 Preparticipation Physical Evaluation Form (Ohio High School Athletic Association)

Adult Health History Form

Authorization to Release Information

Comprehensive Primary Care Plus (CPC+) Information

Consent to Photograph Form

COVID-19 Info Sheet - English

COVID-19 Info Sheet - Nepali

COVID-19 Info Sheet - Spanish

Health Information Exchange Withdraw – Adult

HIPAA Notice of Privacy Practices

New Pediatric Patient Forms

Pediatric Demographic Form

Pediatric Dosing Chart

Receipt of Notice of Privacy Practices

Request to Amend Protected Health Information (PHI) Form

STARK Notice - Patient Information

Adult Demographic/Registration Form

Request to Restrict Protected Health Information (PHI) Form

Request for an Accounting of Disclosures of Protected Health Information (PHI)

Pediatric Health History Form

Pediatric Demographic/Registration Form

Parent/Guardian Consent for COVID-19 Vaccine

New Adult Patient Forms

Health Information Exchange Withdraw – Pediatrics

Designation of Another Person to Consent for Treatment Form

COVID-19 Info Sheet - Somali

COVID-19 Info Sheet - French

COVID-19 Info Sheet - Arabic

Consent for Prescribing Opioids to Minors Form

Checking In for Your Appointment from Home

Agreement of Financial Responsibility Form

Advanced Directives Forms

Ancillary Forms

Cardiac Testing

Caffeine Information

Pharmacological Cardiolite Information

Stress Echo Information

Echocardiogram (Echo) Information

Stress Cardiolite Information

Stress Test Only Information

Physical Therapy

Diabetes Management

Africa Road Location Map

Medicare Patient Packet

Other Insurance Patient Packet

Diabetes Management Tips and Information

Bethel Reed Park Location Map

OSU Insurance Patient Packet

Diabetes Management - Healthy Eating Made Simple

Diabetes Management - What's My Plate All About Infographic

Fall Prevention

CDC STEADI Toolkit - Fall Prevention Checklist

Exercise - Sit to Stand Using an Armchair

Exercise - Standing Tandem Balance With Counter Support

Exercise - Heel Toe Raises With Counter Support

Exercise - Standing Heel Raise With Support

Radiology (Imaging)

CT Abdomen - Pelvic

CT Coronary Artery Calcium Screening (CACS)

CT Renal - Kidney Stone

Ultrasound - Stress Arterial

Ultrasound - Renal Artery

Ultrasound - Lower Extremity Venous

Ultrasound - Knee (Popliteal)

Ultrasound - Aorta

Ultrasound - Abdomen

CT Brain - Head

CT Enterography

DEXA Scan Preparation Sheet

Ultrasound - Aorta Screening

Ultrasound - Carotid

Ultrasound - Lower Abdominal

Ultrasound - Renal (Kidney)

Ultrasound - Scrotum

Ultrasound - Thyroid

Balance Difficulties & Falls

Low Back & Sciatica

Upper Extremity (Shoulder, Upper Arm to Hand)

Cervical (Neck or Neck & Shoulder)

Lower Extremity (Hip & Leg)

Vestibular (Dizziness)