Patient Forms

Using the links below, you can download, print and complete the appropriate forms before your appointment.
[Need help opening/printing PDF forms?]

• Patient registration form [PDF]
• Male health history packet:
  • Male urologic history [PDF]
  • American Urological Association Symptom Score Sheet [PDF]
  • Review of Systems [PDF]
• Female health history packet:
  • Female urologic history [PDF]
  • American Urological Association Symptom Score Sheet [PDF]
  • Review of Systems [PDF]

The following will be provided to all new patients:

• Notice of Privacy Practices
• Notice of Privacy Practices Acknowledgement Form [PDF]

What to Bring to Your Appointment

• Your insurance card
• Physician referral form, if required by your insurance provider
• A list of medications, including the dose and frequency
• Information about your medical and surgical history
• Recent x-rays or other test results related to your condition

Insurance and Payment Information

Capital Urology, Inc., is a provider for Medicare and most major insurance plans, and provides insurance billing. You are responsible for charges that are not covered by your insurance, at the time of your appointment. Your insurance company may require a co-payment at the time of your appointment. When necessary, our staff will work with patients to set up a payment plan. If you have questions regarding billing or which insurance plans we accept, please call us at the phone number below. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Hospital Affiliations

• Riverside Hospital - Columbus, OH
• Mount Carmel St. Ann's - Westerville, Ohio
• Mt. Carmel East Hospital - Columbus, OH
• Knightsbridge Surgery Center - Columbus, OH
• American Kidney Stone Management - Columbus, OH
• Grant Hospital - Columbus, OH