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Patient & Release Forms

Patient Agreement

& HIPPA Information

Request An Appointment

Appointment Type

PCC Office

Full Name

Parent/Guardian

Phone

Email

Address

Age

Gender

Date of Birth

Availability for Scheduling

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Saturday AM

Saturday PM

Referred By

Reason for Referral

Specific Therapist

Insurance 1

Policy Number 1

Insurance Holder

Insurance 2

Policy Number 2

Insurance Holder

Insured Name 1

Group Number 1

Insurance Holder DOB

Insured Name 2

Group Number 2

Insurance Holder DOB

Thank You for Contacting Us! We Will Be In Touch.

Online Patient Form

African American Man Smiling

POLAND OFFICE

3292 Stones Throw Ave
Poland, OH 44514
330-757-3975

Mon.-Thurs. 8am-9pm

Fri. 8am-5pm

Sat. 8am-1pm

Closed Sunday

HOWLAND OFFICE

425 Niles Cortland Road SE Suite 201
Warren, OH 44484
330-856-3975

Mon.-Fri. 7:30am-8pm

Sat. 9am-2pm

Closed Sunday

CANFIELD OFFICE

6715 Tippecanoe Road Ste F200
Canfield, OH 44406
330-967-4957

Mon.-Thurs. 8am-8pm

Fri. 8am-5pm

Closed Saturday

Closed Sunday

PAYMENT TYPES

Insurance,

Personal Checks,

All Major Credit Cards,

& Debit

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