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New Patients

In order to best serve you, and ensure our no-wait policy, we ask that you please print, read and fill out the following forms prior to your first visit/physical at Olentangy Private Internal Medicine. Just click on each form to read and print! You must have Adobe Acrobat installed to view the forms below. Click here to download free!

Please read the 'Privacy Policy' and 'Patient Rights/Responsibilities' below,
and print for your own records.You do not need to bring these to the office.

Please print & sign the 'Receipt of Patient Information' form, acknowledging that you have read the above documents, and bring to your first appointment.

Please print & fill out 'Patient Information,' 'Release of Information from Previous Physician,' & 'Patient-Physician Agreement' & bring to your first appointment.

Patient
Information

1 page

Patient Rights and
Responsibilities

2 pages

Privacy
Statement

2 pages

Receipt of Patient
Information

1 page

"I play hockey and the guys in my league play hard. That means I get hurt every couple of months. I first rang Dr. Miller for a hyper-extended thumb. I was on my way out of town and couldn't wait hours at an urgent care. I saw Dr. Miller within the hour."

- Hamish B., President of a small clinical research company

Patient - Physican
Agreement

3 pageS

Release of Information
from former physician

1 page