Forms + Documents
Here we’ve assembled many of our medical forms and documents in one place for your convenience. Please print and fill out your documents prior to your visit for an even faster in-office experience.
New Patient Packet
Everything a new patients needs. Please fill out and bring these forms to your first appointment. Packet includes:
• Patient Registration
• New Patient Medical History
• Receipt of Privacy & Acknowledgement
• Financial Policy
• Authorization to Treat & Financial Policy Signature
• Release of PHI to FPCW
• New Patient Partnership Letter
• Welcome Page
*Click the form title in the list to download each document individually.
Contains both the Ohio Living Will and the Ohio Durable Power of Attorney forms. Completing these forms gives your family and healthcare providers important information regarding your wishes in the event that you become incapacitated.
Certification of Health Care Provider
This is an optional form that an employer may use if it chooses to require certification from a healthcare provider that a serious health condition requiring leave under the Family and Medical Leave Act (FMLA) exists.
DNR-CC Packet (Do Not Resuscitate – Comfort Care Only)
Expresses your wish not to be resuscitated under special circumstances. Packet includes information regarding your right to refuse treatment as well as the form that needs to be completed to do so. Must be completed by you and your doctor.
Release of PHI from FPCW
This allows us to send your medical records to a new physician.
Release of PHI to FPCW
This allows us to obtain your medical records from a past physician.
Outlines our policy on payment and billing, as well as other important financial information. Please read this thoroughly before signing the Authorization to Treat & Financial Policy Signature Form.
Outlines the general policies within Family Practice Center of Wadsworth. New patients should especially be aware of the general policies of the practice.
Boy Scout Physical Forms
Contains both the Class I and Class II physicals. Class I is an annual update by parents and is needed for any events lasting under 72 hours. Class II requires a doctor's visit and is needed for any scouting events lasting over 72 hours.
OHSAA Pre-participation Form
Must be completed in order for any student to be eligible for interscholastic athletics.
Physician’s Certificate for a Minor’s Work Permit
For minors who are required to take a physical for employment purposes.
Disabled Person License Plate Application
Certifies that you have a condition that warrants the issue of a DP plate.
Disabled Person Placard Plate Application
Certifies that you have a condition that warrants the issue of a DP placard.