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Information Update Packet

We need to make sure we have the most up-to-date information about all our patients each year. To make things run smoothly, please print and fill out this packet if you haven't yet been seen in the current calendar year.

• Information Update Packet

Minor Consent

Minors cannot authorize treatment for themselves. This form allows our practice to treat a minor in the absence of their legal guardian, should the need arise.

• Minor Consent Form

Physical Form

If you are having a physical with Dr. Lutz, please print out this medical history form and fill it out before coming in.

• History and Physical Form

Bone Densitometry

If you are going to have a bone density scan, you are required to fill out a questionnaire to help us analyze your scan. If possible, please print and fill out this form and bring it with you to the office to make your appointment run more smoothly.

• Bone Densitometry Patient Questionnaire

Refill Requests

If you would prefer to fax a form in to our office rather than using our Online Refill Request System, you can use this form.

• Refill Request Fax Form

Athletics Forms

OHSAA Physical

The Ohio High School Athletic Association requires its athletes to have a physical performed before play. The form has an extensive medical history checklist that must be filled out by the patient. You can print this form and fill our your parts before coming in.

• 2006-07 OHSAA Physical Exam Form

Records Release Forms

More information on records transfer to or from FPOG, as well as forms to authorize transfers and information on the pricing structure, can be found on the Record Requests page.