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  • 1671 North Limestone Street, Springfield, Ohio, 45503-2646
  • Mon-Thu: 9am-5pm, Fri: 9am-12pm
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(937) 324-5511
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    • Cardiac Surgery Services
      • Heart Bypass Surgery
      • Aortic Valve/TAVR
      • Mitral Valve Stenosis
      • Pacemaker and ICD Implants/Battery Change
    • Peripheral Vascular Surgery
      • Balloon Stenting
      • Atherectomy Procedure
      • Venous Procedures
      • Abdominal Aortic Aneurysm
      • Inferior Vena Cava Filter
      • Carotid Stenosis
      • Emobilization / Coiling
      • Dialysis
      • Femoral Bypass Surgery
      • Femoral Endarterectomy
    • Robotic Lung and Esophageal Surgery



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      • Vascular Ultrasound Studies
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(937) 324-5511

Patient Forms

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  • Patient Forms

Below you will find the various forms needed to assist our staff and medical professionals.

Patient Registration Form

For new patients.

Online Form

Financial Policy

Our policy on payment for services.

Online Form

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Download

HIPAA Notice Signature Page

Authorization for treatment and disclosure of information for Treatment, Payment, and Health Care Operations.

Online Form

Medication List

List all medications taken on a regular basis.

Online Form

Screening Questionnaire

Tell us a little about your condition and symptoms.

Online Form

Communication Orders

Please tell us how you prefer to be conacted.

Online Form
Contact us
  • (937) 324-5511
  • Mon-Thu: 9am-5pm
    Fri: 9am-12pm
  • Follow Us
  • Bill Pay
Office address
  • 1671 North Limestone Street
    Springfield, Ohio, 45503-2646
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