For more information, call
513-489-8000 or email

robinson@fuse.net

Forms

The following are some forms which you may be instructed to print and complete prior to your visit. The staff will instruct you on which specific form you may need. Thank you.

Comprehensive Medical History Survey

Billing & Consent Sign in Form

HIPPA Consent for Phi Disc

SYMPTOMS AT START OF THERAPY PROGRAM (Form 21)

MY WEEKLY SYMPTOMS REPORT (Form 22)

MY SYMPTOMS AT COMPLETION THERAPY (Form 23)

SUPPLEMENT to “My Weekly Symptoms Report” for M.D. re-evaluation (Form 20)