Appointments: 859-341-5400

Office Forms

ADHD Forms

This form is required by the state of Kentucky for any controlled substance.
ADHD Information Sheet
Behavior Health Referral List
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 (Refills, Paperwork & More)

Policies

Other Forms

Community Courier Resources

The article explaining iBsafe and how it helps increase knowledge of safety.