Printable Online Forms

Save time by completing any necessary forms before visiting the office. Simply click to view and print.

Registration Form

Complete this form if you are a new patient or if you have had a change in insurance.

Registration Form - Pediatrics

Complete this form for new patients who are under 18 years of age or if the minor has had a change of insurance.

Consent to Treat

All patients must have this paperwork completed.

Consent to Treat - Alternate Request

Parents or legal guardians of PriMed patients under 18 years of age must complete this form if an alternate adult will accompany the child for the visit.

Personal Representative

Enables you to authorize individuals, such as family members or friends, access to your health information.

Family History - Pediatrics

Complete this form for your child prior to their first visit. This information helps us to understand the complete picture of your child's health.

Pediatric Asthma Questionnaires

If your child's doctor has asked you to complete an asthma questionnaire prior to his/her next visit, access it here.

 

Medical History

Complete this health history questionnaire so your physician can review with you during your visit.

Medical History – Endocrinology

Complete this form prior to your first visit so Dr. Mitchell can review your past and present medical information.

Medical History - Neurology

Complete this form prior to your first visit so Dr. Xu can review your past and present medical information.

Child Medical Statement

Complete this Ohio Department of Job and Family Services form for your child to be admitted into daycare and preschool facilities.

Transfer Patient Records

Request your records be sent to a PriMed office, or have our office send your records to another physician or facility.  

Advance Directive

Advance Directives give you a voice in decisions about your medical care when you are unconscious or too ill to communicate.

School Sports Physicals

Please refer to new gudelines from the Ohio High School Athletic Association.