Here you will find our patient forms. 

You can download these, print them and bring them with you for your appointment.

To download, either right-click and 'Save as' or open the link and save them. You must have Adobe Reader to read the files.

Pain Management Initial Patient Paperwork

Healthcare Privacy Notice

Patient History

Broken Appointment Policy

Patient Confidentiality

Patient Demographics

Narcotics & Controlled Substance Agreement


Addiction New Patient Paperwork

Appointed Pharmacy Consent Form

Medical History Form

Patient Intake - Social, Family History Form

Consent - Confidential Form

Narcotics & Controlled Substance Agreement

Clinical Opioid Withdrawal Scales


Contact Us

4523 Cemetery Rd
Hilliard, OH 43026
Call for Appointment: 614-876-1618
Fax: 888-990-1755


About Us

Dr. Samuel Essandoh M.D. had his residency training at the Columbia College of Physicians and surgeons at the Harlem Hospital in New York, NY.  He did his fellowship in Pain Management at the Memorial Sloan Kettering Cancer Center in Manhattan, New York one of the top two cancer centers in the entire United States where he was thought of as one of the best in the field of Pain management.

He holds three board certifications in Pain Management, Internal Medicine and Palliative Medicine.

He has multiple publications to his credit including pain management in cancer survivors and was a content review expert for palliative medicine guidelines when he was working at the Marshfield Clinic, the main competitor of Mayo Clinic in northern Wisconsin. 

In 2011 and 2012 he was recognized as one of the top pain management physicians in America by the Prestigious Consumers' Research Council of America because of his dedication to patient care and the recognition from his peers and mentors.

Dr Essandoh is also a full member of the American Society of Interventional Pain Physicians.