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Patient Forms


 

Below are forms that you may need for your appointment. Please call our office or see the guidelines below if you are unsure what forms you will need.

Patient Forms

New Patient Registration Form
Medical Health History
FMLA Disability Cover Sheet
HIPPA Form
Payment Agreement Policy

 

Consent to Treat a Minor
Medical Release from PSW to other provider
Medical Release from other provider to PSW
Kick Counts
New OB Ultrasound Form


ABN Medical Form
Dentist Letter Form
Edinburgh Postnatal Depression ScaleOB History Form
Opioids Form

Visit Information:

For every appoint please bring the following:

  • Insurance Card
  • Photo ID
  • COVID Vaccination Card – If you have received the vaccine and can show proof of vaccination, you are not required to wear a mask. Otherwise you will be required to continue to wear your mask until you have been fully vaccinated.
  • Updated Medicine List- You may bring all bottles or a list that includes, Name of Medicine – Dosage – Frequency - Please include all over the counter and vitamin supplements.
  • Copay- If you are unsure of your copay, please contact your insurance provider. Every plan is different.

Annual / Any appointment one year or more since your last visit.

  • If it has been a year or more, you will need to complete the HIPAA form as well as the payment agreement form.


New Patients:

  • All of the above
  • Completed forms: New Patient Registration, Medical Health History, Payment Agreement and HIPAA
  • A nurse will contact you before your appointment. This is to obtain your medical history prior to your appointment, allowing you more time to spend with the provider. This must be completed, or your appointment will need to be rescheduled to a later date.
  • Please arrive 15 Minutes Prior to your appointment.


OB Patients:

  • Please follow all the above guidelines.
  • Please include additional forms: OB History form, New OB Ultrasound Form


Minors:

  • Please include additional form: Minor Consent Form
  • A parent or Legal Guardian must come to the first appointment, and any other appointment that would require a procedure.


Medicare:

  • If you over the age of 65 and have Medicare please include the ABN medical form.


Our Affiliations:

Ohio Valley

Springfield, Ohio Hospitals

Location
Physicians and Surgeons for Women
1821 E High St
Springfield, OH 45505
Phone: 937-200-1472
Fax: 937-323-3363
Office Hours

Get in touch

937-200-1472