skip to Main Content

Patient Forms

Provided below are various forms that require completion prior to your visit. Please download the appropriate form as directed by your physician and/or staff by clicking on the name of the form. If you cannot access the form, you may have to download the Adobe software. This will allow you to download this software,providing access to the forms. Please print and bring the completed form(s) with you. This will help expedite your time at our office.  Thank you.

If you need any help completing these forms, have questions about our treatments and procedures, or need to schedule an appointment, please call us at (740) 454-1216 or Toll Free 800-686-7270.

ESA Medical History Form »

Consent for Dilation »

HIPAA Privacy Notice »

Notice of Nondiscrimination »

Patient Demographic Information »