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 PacketAgreement 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 ConsentThe 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 FormThe 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 FormMissouri 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 FormAway 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 formParent’s ADD Initial Assessment form to help diagnosis.
Parental ADD FormParent’s ADD Follow-up Assessment form to monitor treatment.
Parental ADD FOLLOW-UP FormTeacher’s ADD Initial Assessment form to help diagnosis.
Teacher’s ADD FormTeacher’s ADD Follow-up Assessment form to monitor treatment.
Teacher’s ADD FOLLOW-UP FormInjectable Influenza Questionnaire to decide which type of flu vaccine is right for your child.
Injectable Influenza QuestionnaireIntranasal Influenza Questionnaire to decide which type of flu vaccine is right for your child.
Intranasal Influenza QuestionnairePlease 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.
AAP Home Birth RecommendationsHome Birth Consent