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Patient Forms

For your convenience, please print and fill out all applicable forms and present them to the front desk when you arrive for your office visit.

New Patient Registration Form

New patients can save time during their appointments by completing the New Patient Registration form prior to their visits. Simply print out the form below, fill in the information requested and bring the completed form with you to your appointment.

Complete all areas to the best of your knowledge. In doing so, we will have a better understanding of you and can target any concerns/issues you may have.

Authorization to Release Your Medical Records

To have medical records released, please complete the Authorization Form for Use, Disclosure & to Obtain Protected Health Information (PHI) below.

MyChart Access for Another Person

If you would like another person to have access to your OhioHealth MyChart account, please complete the proxy form below and bring or mail it to your physician’s office.

The general requirements for proxy access to an OhioHealth MyChart account record are: 

  • This Authorization for Proxy Access form must be completed, with the appropriate information provided and signed. 
  • Each individual requesting proxy access to a patient’s OhioHealth MyChart account record must have their own OhioHealth MyChart account.
  • If the individual requesting access does not have an account, OhioHealth will provide an OhioHealth MyChart Activation Letter with instructions on how to create one.

MyChart Proxy Form (PDF)