Sign Up For News And Updates

First Name:
Last Name:
E-mail Address:
Sign up for the following:



Address:
City:
State:
ZIP:
Mobile Phone:

New Patient Application



  • Please select Health Center and Provider to meet your primary healthcare needs:


  • Barnesville:






  • Freeport:



  • Caldwell:


  • Quaker City:


  • Woodsfield:




  • Barnesville Dental - Freeport Dental:



  • Date:



  • Date of Birth:

  • Age:


  • Previous Doctor:

  • Reason For Leaving That Doctor:

  • Pharmacy:

  • Name of Insurance:

  • Any Worker's Compensation Claim:



  • Medical History (check if present):









  • Location:

  • Treatment:

  • When Diagnosed:

  • Surgical History:

  • Additional Health Problems:

  • Medications And Reason For Taking (If Known):

  • How Did You Hear About Ohio Hills Health Centers:








* = Required