Forms

Print, complete and sign these forms as needed.

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

Patient Registration Packet

Agreement for authorization to release information in medical and accounting records, financial obligation, privacy practices, and consent for treatment.

Notice of Privacy Practices, Authorization, Financial Obligation and Consent

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.

Shared Information 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.

Records Release 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

Sports Physical Form

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.

Away From Home Care form

Parent’s ADD Initial Assessment form to help diagnosis.

Parental ADD Form

Parent’s ADD Follow-up Assessment form to monitor treatment.

Parental ADD FOLLOW-UP Form

Teacher’s ADD Initial Assessment form to help diagnosis.

Teacher’s ADD Form

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

Teacher’s ADD FOLLOW-UP Form

Injectable Influenza Questionnaire to decide which type of flu vaccine is right for your child.

Injectable Influenza Questionnaire

Intranasal Influenza Questionnaire to decide which type of flu vaccine is right for your child.