Patient Forms

Please read this page carefully
and make sure that the required paperwork
arrives as requested.

No one likes paperwork, but it is a fact of life.  And unfortunately, paperwork and computer work have increased dramatically for us with telemedicine.  So, we are striving to make the process of paperwork and computer work as easy as possible for everyone.  Also, this procedure helps us to keep costs low for you.

Please see Appointment Information for more about the telemedicine procedure.

New Patient Forms

1. Welcome Packet (single-sided, return entire packet)

2. Copy of official photo identification, such as driver's license or passport.

3. Pertinent labs or tests arranged by dates with the most current on top and without staples.  (We do not need duplicate labs over the years; just the most current.  Also, we do not need previous office notes.)

Please MAIL the above items to 123 Emmons Place, Mount Orab, Ohio, 45154 so that they arrive within one week after you schedule your appointment
(Please do not scan/email or fax these forms; we need the originals.)

If the appointment is for your child, then ALL parents/guardians must sign the paperwork; you can use your photo ID.

If you do not have Medicare, then you do not need to sign the Medicare form found in the Welcome Packet.

The diagram in the Welcome Packet is for you; you do not need to return it.

Follow-Up Visit Forms

1. Medication and Supplement List (single-sided)

2. Symptom List (single-sided)

3. Telemedicine Consent (only if you have not already signed a copy, single-sided)

4. Patient Registration (only if your contact information has changed)

Please make sure that the above forms arrive 2-5 days prior to your appointment so that we can get ready for your appointment. 

You can email  ( OR fax them (937-444-4385) OR mail them (123 Emmons Place, Mount Orab, Ohio 45154).

Thank you so very much for assuring
that your competed forms and payment arrive as above!

Let food

be thy medicine, 

and medicine 

be thy food.  




Your word

is a lamp

to my feet

and a light

to my path.

~Psalm 119:105



The secret of health

for both mind and body

is not to mourn for the past,

worry about the future,

or anticipate troubles,

but to live in the present moment wisely and earnestly.

~Buddha (paraphrased)