Patient Forms

The following forms are available for you to review and complete prior to your visit.

Patient Registration

Complete the patient registration form online or print and fax it to 614-851-1444. 

Submit Online: Patient Registration Form (Select this option to complete this form online.)


Print PDF: Patient Registration Form (Select this option to print and complete this form prior to your visit.)

Other Forms

Print, review, and complete the following forms and bring them to your visit. Printed forms will also be available when you arrive.

Authorization to Release Medical Information

Acknowledgment of Receipt of Notice of Privacy

Pain Contract

Consent for Chronic Opioid Therapy

Financial Responsibility Agreement

Information Release

Patient's Bill of Rights and Responsibilities

Disclosure Information

Agreement for Opiate Therapy