Forms

Registration and Reimbursement Forms:

For your convenience, you can download and print our forms. Please print clearly and complete the entire form. Please note: that services are not available until a completed “Client Intake” form is received and approved. Mileage Reimbursement & Prescription Assistance programs are income-based.  If you have any questions regarding these forms or available services, please call our office at 419-626-4548. Our Patient Services Coordinator is available Monday – Friday, 9 am – 3 pm.

Please click on the forms below to access the fillable documents. 

Client Intake Form (page 1)
Mileage Reimbursement Form