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 Patients

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
FPCW Privacy Policy
• 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. 


Medical Forms

Advance Directive 
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.


Policies

Financial Policy 
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.

General Policies 
Outlines the general policies within Family Practice Center of Wadsworth. New patients should especially be aware of the general policies of the practice.


Physical Forms

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.


Disability Forms

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.