New to JBMD? WELCOME!!

First, Please complete the following :

* New Patient Intake Form (completed form automatically sent to our office) 

Next, Email the following to officemanager.jbmd@gmail.com :

* Credit Card on File Form (Download the PDF. Be sure to save before sending)  

* Copy of Drivers License and Front/Back of Insurance card 

Complete the TeleHealth Consent IF you are being see via TeleHealth (completed form automatically sent to our office) 

New Patient Intake Forms 

Release of Information

Office Desk

Credit Card on File

Click to Download the Fillable PDF File. Once completed, save the form and send to:

 officemanager.jbmd@gmail.com 

Thank you!

TeleHealth Consent

Phone App

* This form is to be completed if using TeleHealth services 

Additional Information

*This form is used if you wish to grant  permission for JBMD to share information with another person or office. 

Resources

THE PRACTICE

830 W. South Boundary Street

Suite A

Perrysburg Ohio 43551

Tel: 419. 931. 3020

Fax: 419. 931. 3022

Hours Vary by Appointment

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Sunday: Closed

TO SCHEDULE AN APPOINTMENT: 

Call 419. 931. 3020

Appointments may be scheduled outside of general office hours, depending on your providers availability, and on a case by case basis.

All hours are Eastern Daylight Time (EDT / GMT -5:00)

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© 2018 Julia Burrow, MD & Associates. All Rights Reserved.