Patient Forms

Need a well visit appointment, paperwork, or medication refill?

Go to our Patient Portal.

Office Forms

ADHD Forms

ADHD Information Sheet
Guidelines for ADHD Scheduling

Financial Policy

New patients must review and acknowledge this form.
Please sign this form and bring it into the office at your first visit

Foster Care

Please fill out this form for any new foster children you are caring for.

Influenza

This form is required for our flu vaccine clinics.

Notice of Privacy Practices

This form shows how we use and secure your protected health information (PHI). It must be reviewed and signed by new patients.
Please sign this form and bring it in at your first visit.
All patients 18 years and older need to fill this out so we have permission to release records and talk to their designated family members. This includes access to the portal.

Records Release

Please fill this out to get records from outside physicians, clinics, hospitals and school psychologists.
Consent to Treat Form

Sports Physicals

Print and fill this out if your child plays middle school sports. We can sign it at your annual well visit.
Print and fill this out if your child plays high school sports. We can sign it at your annual well visit.
Print and fill this out if your child plays high school sports in Ohio. We can sign it at your annual well visit.
Print and fill this out for your high school student playing sports in Indiana. We will review and sign it at your annual well visit.

Patient Portal

We are excited to bring you our patient portal from Office Practicum, our electronic health record. The first time you use the portal you will need to verify your children's names, dates of birth, and demographic information.  Please also fill out how you want to be notified of appointment reminders, test results, etc.  

The portal will allow you to view your child's drug allergies, medications, growth charts, vaccines (including a forecast of upcoming shots), pay your bill, request a well or ill visit and even schedule a flu vaccine appointment!  We will also send some forms and documents to the portal for your convenience.

Financial Policies & FAQ's

Financial Policies