Patient forms
We’re here to help.
Save time by printing and filling out your forms in advance.
Medical Clinic Forms
Print, fill out, and bring the Demographic Form to your first visit or first visit of each year.
Routine Forms
Bring these forms, filled out and printed, to your appointment when needed.
- Current Medications List Form (PDF)
- School Physical Form on the KSHSAA website
Additional Forms & Documents
Bring these forms, filled out and printed, to your appointment when needed.
- Treatment Authorization and Privacy Acknowledgment (PDF)
- Clinic Release of Info Request (PDF)
- Hospital Release of Info Request (PDF)
- Patient Rights and Responsibilities – English (PDF) or Spanish (PDF)
- Notice of Privacy Practices (PDF)
- Medical Clinic’s HIPAA Consent – English (PDF) or Spanish (PDF)
- Radiology Nuclear Medicine Stress Test (PDF)
Children’s Well Child Exam
These forms and materials relate to preventive health supervision and health screening for infants, children, and adolescents. If you are bringing your child in for a well-child exam, please click on the following link: