FORMS & RESOURCES

PATIENT REGISTRATION FORMS

Please complete all forms that apply and bring them to your first appointment. You may also email completed forms to FHCQA@woodcountyhospital.org prior to your visit.

General New Patient Registration Form
New Male Patient Health Form
New Female Patient Health Form

Dr. Nowakowski New Patient Forms

New Patient Form

Dr. Nagra New Patient Forms

Female New Patient Form
Male New Patient Form

Kati Bailey, CNP, New Patient Forms

New Female Patient Women’s Health Form
New Male Patient Men’s Health Form

Chiropractic New Patient Forms

In order to provide you with the most accurate information regarding any possible out of pocket expense for the care that you may be receiving, we ask that you please contact your insurance company to confirm that your insurance includes chiropractic care. Please note that this is not a guarantee of your out-of-pocket expense. If you have any questions, please contact our office at 419-728-0601. 

ADL Form for New Patients
Chiropractic Insurance Benefits Questionnaire
Chiropractic Health History Form

Authorization for Release of Medical Information

The form must be completed by the patient when they would like a copy of their medical records provided to them or another healthcare provider. This form must also be completed by the patient when giving the Falcon Health Center permission to disclose personal health information for reasons other than treatment, payment or health care operations. There may be a charge for copies.

Verification of Medication Orders

This form must be completed by a physician for those requiring administration of medication. In addition to a prescription sent to the pharmacy, our physicians will need a doctor’s order from the prescribing physician with information about the last administration. This information can be faxed to our office at 419.354.3222

High School Physical Clinic Forms

Please print and complete the following forms and bring to the high school physical clinic. These forms are necessary for the physical to be completed. We will be unable to see any patients that do not have completed forms.