HAROLD F. ROTH, D.O.
HAROLD F. ROTH, D.O.

Contact and Appointments

 

HAROLD F. ROTH, D.O.

1627 Lake Lansing Road

Suite 200

Lansing, MI 48912-3788

 

Phone

(517) 485-1789

Fax

(517)485-2357

 

Business Hours

Monday - Friday: 8:00am-4:00pm Closed Daily from Noon to 2:00pm

New Online Presence

Explore our new website to find out everything about our practice.

 

Patient Information

Everything you need to know about your visit to the doctor.

More

Forms for New office Patients -- see forms for afc facilities for the adult foster care patients

2017 Forms

Patient Registration Form
PATIENT REGISTRATION FORM 011416d.pdf
Adobe Acrobat document [198.4 KB]
Adult History Form
ADULT HX FORM.pdf
Adobe Acrobat document [85.7 KB]
Pediatric History Form
PEDIATRIC HX FORM.pdf
Adobe Acrobat document [83.9 KB]
Ongoing Office Policy 2017 Form
ONGOING OFFICE POLICY 2017-PURPLE-122916[...]
Adobe Acrobat document [131.5 KB]
Insurance Authorization and Assignment of Benefits
INSURANCE AUTHORIZATION AND ASSIGNMENT O[...]
Adobe Acrobat document [200.1 KB]
List of Current Medications Form
medication intake form-101514.pdf
Adobe Acrobat document [222.1 KB]
Medical Release
MEDICAL RELEASE-YELLOW-101514.pdf
Adobe Acrobat document [189.3 KB]

Sports Physical and Preschool Physical Forms

MHSAA Physical Form
2011 MHSAA 2 PAGE PHYSICAL FORM-110414.p[...]
Adobe Acrobat document [171.3 KB]
Preschool Physical Form
PHYSICAL FORM FOR PRESCHOOL-BCAL-3305_09[...]
Adobe Acrobat document [50.2 KB]

MVA & Workers' Comp Questionnaires

MVA Questionnaire Form
motor vehicle accident questionnaire-110[...]
Adobe Acrobat document [85.3 KB]
Worker Comp Questionnaire
work related injury questionnaire-110414[...]
Adobe Acrobat document [84.9 KB]
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