All Points Medicine

Poland: 330.758.8223

Columbiana: 330.482.6063

Patient Resources

New Patient Form

Below is the New Patient Registration Form. You may click on the icon or link to view the form in PDF. To do so, you will need Adobe Acrobat Reader to read and print files in Portable Document Format (PDF). If you do not have Acrobat Reader installed please first click the Acrobat link to download your free software before downloading the New Patient Registration Form. (Make sure Acrobat is completely installed before attemping to view our form).

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Please fill out the entire form and bring it to your first appointment.

NEW PATIENT REGISTRATION FORM


In addition, please bring the following information on your first visit:

  • Any x-ray, MRI or CT scan films or reports that you already have in your possession. We will call your facilities for a report if it is inconvenient for you to obtain them.
  • A list of all medications you are taking, including non-prescription medications or vitamins.
  • All patients under the age of 18 must be accompanied by a parent or guardian.
  • No preparation is needed if you are scheduled for an EMG/NCV test. However, we ask that you do not apply lotion to your skin in the area to be tested.
  • Your insurance cards along with your co-pay. Payment at the time of service is required for all co-pays. Please contact our office regarding our fees and payment policies if you are without insurance coverage.