Before you visit us at Dayton Gastro for your next appointment or procedure, please feel free to print and fill out the appropriate forms below. If you are not sure about which forms to fill out, please contact us.

If you have not seen us in the last three years, we will need an updated Medications and Allergies + updated Medical History form that you can find below.

New Patient - Office Visit

New Patient - Procedure

Patient Consent Forms

Patient Information Forms

USPI ASC Information Forms

NOTE: Our Ambulatory Surgery Centers (ASCs) may be partly owned by physicians. A list of physicians who have a financial interest in our ASC locations is available upon request.
USPI ASC Good Faith Estimate Form
USPI ASC Nondiscrimination Notice
USPI ASC Notice of Privacy Practices (Español)
USPI ASC Patient Rights
USPI ASC No Surprise Act