Family Medicine of Stark County
6512 Whipple Avenue Northwest
North Canton, OH 44720
Phone : 330-499-5600
 
Important Forms
 
Please take a moment to review our privacy policies and fill out our new patient and patient information forms before your first visit.

New Patient History Form
This form contains family history and other medical information. Please fill out both pages prior to your first visit.

New Patient Demo
Back of Demo Sheet

Privacy Policy
Please print a copy for your records. This outlines the HIPPA Privacy Laws and our Privacy Policy.

Patient Information
This sheet will stay in your chart, and contains all the contact and vital information to receive quality care. Please fill this out completely, otherwise problems may arise later. At the bottom of the sheet is the signature line to confirm the information is correct and to verify that you received a copy of the Privacy Policy.

Authorization
This paper outlines our office policies and gives us permission to bill your insurance company. This paper must be signed each year. If you would like a copy for your records we will be happy to provide you with one. It is very important that you read and understand our office policies.

Health Maintenance Exam
This year you will most likely be asked to schedule a preventive Health Maintenance Exam (HME). During this exam your physician or assigned practitioner will perform a comprehensive exam based on your age, gender and risk factors and order the appropriate screening factors that may detect any abnormalities. Most insurers cover and encourage preventive exams. See the form for more details.

Phone Message Consent
From time-to-time in caring for our patients, it may be necessary or desirable to contact patients by phone. When you are not available for us to speak to directly, we like to leave messages where possible.