Form Center

Patient Information Form	Health History Form

In advance of your visit, please fill out these forms. We will have them printed and in your file when you arrive. You will need to sign them on your first visit to the office. If you have previously completed a form and this is an update, please ensure all details are included because your old forms are shredded.

We also ask that you always bring your most current insurance card so it can be scanned in your child’s file. Insurance information or changes require a new copy of your card, and cannot be simply amended with the completion of a new form. If you would like to fax an enlarged copy of both the front and back of your card rather than scanning one in the office, you may do so. Our fax number is 913-384-5209. Thank you.

These forms will be sent securely to our office

Release of Medical Records - < click to open >

If you desire a complete copy of your child’s chart, a signed release and payment will be required prior to the release of the copied chart. A parent or legal guardian may request the following information: a copy of the immunization record, growth chart and last well check-up for a fee of $5.00 per child. Any additional copies of the above information or any other copying requests for the patient will be billed at the rate governed by Kansas law (KSA 65-.4971b). These rates change yearly by law and can be quoted to you over the phone. The copy will be ready within 30 days after payment is received and you will be notified by phone. Please contact the office with any further questions regarding this policy.

Organization /School Forms

Boy Scout Camp Form	KS High School Athlethic Form	MO High School Athlethic Form	KS Daycare Health Form	KS Certificate of Immunization	KS Asthma Action Plan