Health History & Patient Information
Patient contact information, insurance details, dental history, medical history, medications, allergies and authorization.
Download health history
Prepare for your visit
Complete your forms before your appointment.
Download the fillable PDFs, enter your information, save a copy and bring the completed forms with you. You may also print them and fill them out by hand.
Patient paperwork
Two forms for a smoother check-in.
For the most reliable experience, download the file before completing it and open it in Adobe Acrobat Reader or another PDF application that supports fillable forms.
Office Financial Policy
Review the office’s payment, insurance, account-balance and appointment policies before acknowledging the form.
Download financial policyProtect your private information: bring the completed forms to your appointment. Please do not send health or insurance information through ordinary email unless the office specifically provides a secure method. The team can verify any signature or witness fields when you arrive.
Need help?
Call (330) 385-9496
Questions about the forms?
Call the office during regular hours and the team will be glad to help.