If you are experiencing technical difficulties registering for your appointment, our patient registration forms are still available to download, print and fill out at your convenience. Please PRINT the forms and bring them in with you to your appointment.
If you would like to authorize Proliance Surgeons to use or disclose your health information to another party, please print and complete the form below:
If you have a child under the age of 18 years old and you will be authorizing another adult to attend your child’s appointment or authorizing the child to come to the appointment without an adult, please print and complete the form below. PHWE strongly encourages parents and guardians to be part of their minor’s or care.