Patient Forms

Patient Registration Packet

The New Patient Registration Packet includes forms for new patients to complete and return at least two weeks before their first visit.

Privacy Practices, Authorization, Financial Obligation and Consent

Agreement for authorization to release information in medical and accounting records, financial obligation, privacy practices, and consent for treatment. VIEW OUR HIPAA POLICY HERE

Shared Information Form

The Shared Information Document filed with our office gives us your written permission to speak with other persons such as a babysitter, grandparent, school nurse or athletic trainer about your child’s health.

Records Release Form

The Medical Records Release Form should be mailed to your previous provider(s). We suggest having the copy sent to you to be kept permanently at home. We will scan pertinent parts of your copy into our electronic record.

Sports Physical Form

Missouri Sports Physical Form (MSHSAA) Please note that the parent/student sections are to be completed before the physician signs the form. Completed forms will be returned to parent or patient only; we are no longer able to fax to schools

Child Care-Daycare Form

This form will be needed if your child is going to a licensed daycare or child care in Missouri.

Boy Scouts of America Camp Form

Form for child going to scout camp. Check-ups must be up to date for us to complete this form. Please call 417-882-1600 to schedule.

Away From Home Care

Away From Home Care form for when your child will be staying with someone else while you are away. Form should be left with the person that is caring for your child.

Parent ADD Initial Form

Parent’s ADD Initial assessment form to help diagnosis.

Parent ADD Follow-up Form

Parent's ADD Follow-up assessment form to monitor treatment.

Teacher ADD Initial Form

Teacher’s ADD Initial assessment form to help diagnosis.

Teacher ADD Follow-up Form

Teacher’s ADD Follow-up assessment form to monitor treatment.

AAP Home Birth

Please sign and mail this form to our office after reviewing the AAP recommendations on home birth if you are planning to deliver your baby at home.