Worthington Family Physicians Patient Forms

Below are the forms that are frequently used at our COPC practices. It will save time when you arrive for your first appointment if you're able to complete those relevant beforehand and bring them with you to your appointment. Please contact us if you have any questions.

Adult Demographic / Registration Form

Adult Health History Form

Pediatric Demographic / Registration Form

Pediatric Health History Form

Authorization to Release Information

Notice of Privacy Practices

Request to Amend Protected Health Information

Consent To Photograph

Request to Restrict Protected Health Information

CPC+ Information

Request to an Accounting of Disclosures

Advanced Directives Forms

Consent Form for Prescribing Opioids to Minors

Designation of Another Person to Consent for Treatment

STARK Notice - Patient Information Sheet