patient forms

To expedite your care, we encourage you to thoroughly complete your forms prior to your appointment.

New Patients: Please contact FWO’s Intake Team, 260-436-8686 ext 5019, prior to your appointment to complete/update your medical history.

Release of Information: FWO utilizes the services of a third party vendor (HealthPort) to complete patient FMLA and Disability forms along with requests for medical record copies. Patients will be billed separately for those services rendered by HealthPort. To request these services, please complete and return the Authorization form. Completed forms can be faxed to 260-434-2701.