New Medical Patient Application



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


  • BARNESVILLE:






  • BELLAIRE:


  • FREEPORT:



  • QUAKER CITY:


  • WOODSFIELD:




  • Date:


  • Phone: *

  • E-Mail:

  • Contact Preference:




  • Date of Birth: *

  • Age:

  • Sex:


  • Name of Parent or Guardian:

  • Parent or Guardian Phone Number:

  • 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