Patient Forms

To help us provide you with better care, please download, print, and sign any of the forms below needed for your appointment. In most cases, patients are highly advised to complete the corresponding Medical History Questionnaire, and the Medical Record Release Form if you seek to obtain a copy of your records.

Please be sure to bring any completed forms with you to your appointment. Thank you for your assistance in helping us provide you with excellent care.

New OSMI Appointments

Patients who are first time visitors, should print, sign and bring this form with them:

• OSMI New Patient Medical History Questionnaire (PDF)

Radiology Appointments

Patients who have an upcoming radiology visit, should print, sign and bring this form with them:

• Medical History Questionnaire (PDF)

Physical Therapy Appointments

Patients who have an upcoming therapy visit, should print, sign and bring these forms with them:

• Medical History Questionnaire (PDF)
• Health Survey (PDF)
• Attendance Policy (PDF)

Functionality Questionnaire

(Choose the one that matches the location of your injury)

• Knee: Download Form (.pdf)
• Lower Extremity: Download Form (.pdf)
• Lower Back: Download Form (.pdf)
• Shoulder: Download Form (.pdf)
• Neck: Download Form (.pdf)

E-mail Communication with OSMI Physicians

Patients wishing to establish email communications with their physician, should print, sign and bring this form with them to the next appointment:

• Disclose PHI via Electronic Media (PDF)

Referring Physicians

Please print and fax this Consultation/Transfer of Care Request to 352.273.7293:

• Consultation/Transfer of Care Request (PDF)

Guests and Visitors

If you are not a patient, and wish to observe or tour OSMI, you should print, sign and bring these forms with you:

• Observing at The OSMI (PDF)
• OSMI Confidentiality Statement (PDF)