Thu, Apr 26, 2018
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Resources Patient Forms

Prior to beginning your first appointment, you will need to complete and sign a few forms.  These forms can be downloaded and printed below to provide you the convenience of reviewing the documents in your own home.  When you arrive at Dayton Artificial Limb, we will review these documents with you and collect any necessary signatures.

If you have any questions, please call our office at 937-898-2200.

FileDescriptionFile size
Download this file (NP Bill of Rights 5-10.pdf)Patient Bill of Rights 174 Kb
Download this file (NP DEMEPOS HIPPA 5-10.pdf)Consent for Treatment 421 Kb
Download this file (NP Financial Respo 5-10.pdf)Financial Responsibility 161 Kb
Download this file (PT Attendance Policy 6-2010.pdf)Physical Therapy Patient Attendance Policy 187 Kb

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“I think all the people who have helped so far have been excellent at what they do. Luci has been very excellent and has taken her time to do my leg right. Keep up the good work.” – Peter Sujka

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