Forms

New Patient Forms

Completing and submitting the following forms before your first OB/GYN appointment will save you time upon arrival at your care center.

Click here to upload your supporting documents, including a copy of your insurance card or identification.

Medical Release

We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information. To request your medical records visit medicopy.net/axia.

Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary.

If you have any questions, please contact MediCopy: Online Chat: MediCopy.net | Phone: 866-587-6274 | Ask a Question: https://medicopy.net/contact
Learn more about MediCopy’s Release of Information service

Returning Patient Forms

To ensure we have the most accurate and current information, we ask our returning patients to complete the following form once per year.

Mammography Release Forms

In New Jersey and Pennsylvania:

In Ohio/Kentucky:


NOTE: If you are a Southside OB/GYN, OB/GYN of Indiana, Seven Hills Women’s Health Center, or Lexington Women’s Health patient and are looking for disability or FMLA forms, click here.