Forms

Patient Forms

Patient In-Take Packet

Minor Consent Form

BGSU Firelands Patient Packet

Edison Local Schools Patient Packet

Huron Local Schools Patient Packet

Monroeville Local Schools Patient Packet

Margaretta Local Schools Patient Packet

Sandusky City Schools Patient Packet

Townsend Community School Patient Packet

Vermilion Local Schools Patient Packet

Western Reserve Local Schools Patient Packet

Additional Forms

Sliding Fee Scale Application

Request for Transcript of Tax Return

Authorization to Release Medical Records

HIPAA Authorization Form

Patients Rights and Responsibilities

Patient Privacy Notice