Patient Forms
Download patient forms and fill them out for your next appointment with Physicians & Surgeons for Women in Springfield and Urbana, OH and experience the best in OBGYN.
Access our patient portal here, https://physurg.portalforpatients.com/portal.
Patient Forms
Our Affiliations
Visit Information
Please see below for a list of what you should bring when you come in to our office for your obstetrics or gynecology appointment.
New patients:
- Please bring past medical records or ask your physician to fax them to 937-323-3363937-323-3363 prior to your scheduled appointment.
- Please plan to arrive 15 minutes prior to your appointment time.
- Please bring completed health questionnaire and patient registration form as seen below.
New and existing patients
- Current Insurance Card
- Photo ID
- All current medications and dosing instructions (actual prescription bottles preferred)
- Over-the-counter supplements or vitamins (actual bottles preferred)
- Co-payment
Patient Forms (Required at time of visit)
- New Patient Registration Form
- Health questionnaire
- Consent to treat minor
- HIPAA privacy notice
- Financial policy
- Patient Responsibility Form: Please read and complete all three sections of this form to indicate that you understand your Patient Responsibilities and that you’ve received a copy of our Notice of Privacy Practices. The third section is very important if you want us to discuss your healthcare information with someone other than yourself. It also allows us to leave messages and voice mail on designated phone numbers that you provide. Please read carefully.
