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're a new patient or to update your demographic information, including your communication preferences.

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 - 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.

Daycare/School Medical Release Form

Complete this form to authorize the release of your child's medical information needed by schools and daycare.

Registration for FollowMyHealth

Patients of our Family Practice and Neurology offices can complete this form to be able to access your health information online. This is also the form for requesting proxy registration (as a patient representative).

Transfer Patient Records

Use this form to request your PriMed records be sent to another physician or facility.

  • Submit completed form by fax to 937-291-6942 or mail to PriMed Physicians, attn: Health Information Department, 235 W. National Rd., Vandalia, OH 45377.
  • This form can also be sent to another physician or facility to request your records be provided to a PriMed office. 

Insurance Forms

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 guidelines from the Ohio High School Athletic Association.