Total Health Center Patient Forms

Patient Forms for Downloading and Printing

General Forms

Below are the generic forms that are frequently used at our practices. If you have any questions regarding our patient forms, please feel free to contact us.

2024-2025 Preparticipation Physical Evaluation Form (Ohio High School Athletic Association)

Download

Adult Demographic/Registration Form

Download

Adult Health History Form

Download

Agreement of Financial Responsibility Form

Download

Authorization to Release Information

Download

Checking In for Your Appointment from Home

Download

Comprehensive Primary Care Plus (CPC+) Information

Download

Consent for Prescribing Opioids to Minors Form

Download

Consent to Photograph Form

Download

COVID-19 Info Sheet - Arabic

Download

COVID-19 Info Sheet - English

Download

COVID-19 Info Sheet - French

Download

COVID-19 Info Sheet - Nepali

Download

COVID-19 Info Sheet - Somali

Download

COVID-19 Info Sheet - Spanish

Download

Designation of Another Person to Consent for Treatment Form

Download

Health Information Exchange Withdraw – Adult

Download

Health Information Exchange Withdraw – Pediatrics

Download

HIPAA Notice of Privacy Practices

Download

New Adult Patient Forms

Download

New Pediatric Patient Forms

Download

Parent/Guardian Consent for COVID-19 Vaccine

Download

Pediatric Demographic Form

Download

Pediatric Dosing Chart

Download

Pediatric Health History Form

Download

Receipt of Notice of Privacy Practices

Download

Request for an Accounting of Disclosures of Protected Health Information (PHI)

Download

Request to Amend Protected Health Information (PHI) Form

Download

Request to Restrict Protected Health Information (PHI) Form

Download

STARK Notice - Patient Information

Download

Viewing Test Results on the Patient Portal and Healow App

Download

Advanced Directives Forms

View

Cardiac Testing

Caffeine Information

Download

Echocardiogram (Echo) Information

Download

Pharmacological Cardiolite Information

Download

Stress Cardiolite Information

Download

Stress Echo Information

Download

Stress Test Only Information

Download

Diabetes Management

Africa Road Location Map

Download

Bethel Reed Park Location Map

Download

Medicare Patient Packet

Download

OSU Insurance Patient Packet

Download

Other Insurance Patient Packet

Download

Diabetes Management - Healthy Eating Made Simple

Download

Diabetes Management Tips and Information

Download

Diabetes Management - What's My Plate All About Infographic

Download

Fall Prevention

CDC STEADI Toolkit - Fall Prevention Checklist

Download

Exercise - Heel Toe Raises With Counter Support

Download

Exercise - Sit to Stand Using an Armchair

Download

Exercise - Standing Heel Raise With Support

Download

Exercise - Standing Tandem Balance With Counter Support

Download

Radiology (Imaging)

CT Abdomen - Pelvic

Download

CT Brain - Head

Download

CT Coronary Artery Calcium Screening (CACS)

Download

CT Enterography

Download

CT Extremities

Download

CT Neck

Download

CT Renal - Kidney Stone

Download

CT Sinus

Download

CT Spine

Download

DEXA Scan Preparation Sheet

Download

Ultrasound - Abdomen

Download

Ultrasound - Aorta Screening

Download

Ultrasound - Aorta

Download

Ultrasound - Carotid

Download

Ultrasound - Knee (Popliteal)

Download

Ultrasound - Lower Abdominal

Download

Ultrasound - Lower Extremity Venous

Download

Ultrasound - Renal (Kidney)

Download

Ultrasound - Renal Artery

Download

Ultrasound - Scrotum

Download

Ultrasound - Stress Arterial

Download

Ultrasound - Thyroid

Download

Physical Therapy

Balance Difficulties & Falls

Download

Cervical (Neck or Neck & Shoulder)

Download

Low Back & Sciatica

Download

Lower Extremity (Hip & Leg)

Download

Upper Extremity (Shoulder, Upper Arm to Hand)

Download

Vestibular (Dizziness)

Download