Patient Forms/Online Registration

Online Patient Registration Form

        New Online Patient Registration Form

Click on this link to access a secure web form version of the required patient medical history paperwork. We created this online option for your convenience and ease of use. You will receive a confirmation upon successfully submitting the form to Youngstown Orthopaedic Associates.

At Youngstown Orthopaedic Associates, we are continually striving to improve your experience when visiting our practice.  To facilitate this, we ask that you complete your required paperwork and send it to us at least 5 days prior to your scheduled visit.

We will require:

1) A completed Demographics form;

2) Your complete Patient Medical History form

3) A signed Privacy Practices (HIPAA) Consent Form, and

4) A signed Financial Policy.

The Demographics and Patient Medical History forms can be completed using the Online Patient Registration Form.

A combined Privacy Practices and Financial Policy form will be presented to you upon your visit for signature.  You can review these Practices and Policies prior to your visit by clicking on the appropriate pdf form below.

If you prefer, you can print the Patient Medical History form for completion and either fax it to 330-729-2758 or mail it to Youngstown Orthopaedic Associates, 6470 Tippecanoe Road, Canfield, OH 44406.  Either way, we do need this information at least (5) days prior to your scheduled appointment.

Any delay will cause you to wait until all of your paperwork is entered into our Electronic Medical Records system prior to your visit with the doctor.  Depending on the day, this could add one hour to your visit.

Please take time to review the forms and sign in the appropriate areas.

Miscellaneous Medical Forms

Forms – General Paperwork

DownloadPatient Medical History Form – General

(PDF Download)

MRI Forms

DownloadMRI Screening Form

(PDF Download)

DownloadMRI Contrast Screening Form

(PDF Download)

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