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: To request copies of your medical records, please complete and return the Release of Information Form. To request completion of a disability or FMLA form, please complete and return the Disability/FMLA Form. Completed forms can be faxed to 260-436-8585. An additional fee will apply for these services and is payable in advance.