4900 Frank Avenue NW, North Canton, OH 44720
330-494-9797 330-499-1241 (Fax)
330-494-9797 330-499-1241 (Fax)
Forms
Below, you will find links to forms used by our office. You can download them and fill them out prior to your first visit, and save yourself a few minutes in the waiting room. Download by right-clicking on the file name and select "save" or "save as". These documents are in PDF format, and require a PDF reader (such as Adobe Acrobat, NitroPDF, or others).
Consent Form - allows other family members to authorize treatment for your child in the absence of his or her legal guardian
Contact Form - list your preferred contact information
Financial Policy - reviews our office financial policy. A signed copy is required for each patient's file.
Insurance Information - demographic and insurance information for the patient and the policy holder(s).
Office Information - Office policies, including privacy policies, patient and physician responsibilities, and other information
Privacy Policy Acknowledgement Form - Acknowledgement that the patient and/or guardian are aware of the office privacy policy (see Office Information, above). Requires signature.
Below, you will find links to forms used by our office. You can download them and fill them out prior to your first visit, and save yourself a few minutes in the waiting room. Download by right-clicking on the file name and select "save" or "save as". These documents are in PDF format, and require a PDF reader (such as Adobe Acrobat, NitroPDF, or others).
Consent Form - allows other family members to authorize treatment for your child in the absence of his or her legal guardian
Contact Form - list your preferred contact information
Financial Policy - reviews our office financial policy. A signed copy is required for each patient's file.
Insurance Information - demographic and insurance information for the patient and the policy holder(s).
Office Information - Office policies, including privacy policies, patient and physician responsibilities, and other information
Privacy Policy Acknowledgement Form - Acknowledgement that the patient and/or guardian are aware of the office privacy policy (see Office Information, above). Requires signature.