Patient Forms


If you are a new patient, please complete a New Patient Registration Form and bring it with you to your first appointment.
 

If you need to transfer your medical records from another medical practice to OhioHealth Surgical Specialists, please complete the Release of Medical Records form below and give it to the medical practice that currently has your records. 

Release of Information form

 

Other Important Patient Forms

History of Present Illness
This form asks you a few questions about the primary symptom or issue that brings you to OhioHealth Surgical Specialists.

Breast Health Questionnaire
This form asks questions about your breast health history and current condition.


Privacy Policy
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.


Patient Responsibilities
This form requires signatures to verify understanding of financial/insurance responsibilities; acknowledgement of receipt of the Practice’s Notice of Privacy (see above); and communication preferences regarding Protected Health Information.

Health History
This form asks questions about your history of illnesses and those of your family.

Medication Reconciliation
This form asks you to list the medications you’re currently taking and to identify any known allergies and reactions, such as allergies to food, latex or medications.
 

Colonoscopy Preparation Instructions

See the instructions for the prep you’ve been directed to use, i.e., Miralax (238 gram bottle) and 1 small bottle of Dulcolax laxative tablets OR GoLytely prescription from the pharmacy. Please read carefully. Failure to follow these instructions EXACTLY as written may result in your procedure being canceled when you arrive at the hospital.

Preparation for Colonoscopy-MagCitrate

Preparation for Colonoscopy-GoLytely