Patient Forms


If you are a new patient, please complete a New Patient Registration Form and bring 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

Please bring these completed forms to your first office visit.

Privacy Policy (information only) 
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.

New Patient Paperwork
Complete the questions on this form to share with us your allergies, medications, family history and past medical history.

Colonoscopy Preparation Instructions

Select 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 Colonscopy-Miralax

Preparation for Colonoscopy-GoLytely