Patient Forms

Please read this page carefully
and make sure that the required paperwork
arrives before your appointment.

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

New Patient Forms

Please either mail (123 Emmons Place, Mount Orab, Ohio 45154) OR fax (937-444-4385) the following new patient forms to arrive before 6 pm by the day prior to your appointment. 

If the appointment is for your child, then ALL parents/guardians must sign the paperwork or the minor cannot be seen.

  • Copy of official photo identification, such as driver's license or passport.  (If the appointment is for your child, then use your photo ID.)
  • Medicare Form - Medicare requires this form. Please send back only if you have Medicare.  They want to make sure that you know that Dr. Bazylewicz does not take Medicare.
  • Diagram - No need to send this diagram back.  We will go over it during your appointment.

Follow-Up Visit Forms

In order to concentrate more on you and your treatment at your follow-up visits, please make sure that your follow-up forms arrive by 6 pm on the day prior to your appointment.

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

Other Documents (Labs, Tests, Reports, etc)

If you have quite a few pages of labs, tests, or reports, please mail them.

If you just have a few pages, they can be emailed OR faxed OR mailed with your  new patient forms or follow-up forms as indicated above.

Thank you so very much for making this process easy!

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)