Dr. Tolga Icli
Opiate Addiction Recovery and Weight Loss Clinic
1450 S Canfield Niles Rd
Austintown, OH 44515
Phone: 234-434-2290
Fax: 330-799-8754
Dr. Daniel A. Miller
Opiate Recovery Patient Forms
All NEW Patients must complete ALL of these forms | ||
| ||
Adult History Form | ||
Medical Information Release | ||
Medical Records Release | ||
Patient Consent Form | ||
Patient Information Form | ||
Patient Survey Form | ||
Suboxone Agreement | ||