Listed below are several forms for you to fill out and bring into the office. Please read these forms carefully and fill them out as completely as possible. This will help us get your information into our system faster, allowing for faster service and insurance payment.
 


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Our Main Office:

8919 Parallel Parkway
Suite 270
Kansas City, KS 66112

Ph: 913-788-7111
Fax: 913-788-3702

Hours: M-F 8am-5pm

Click Here for Map
 


 

 

 
When Making Appointments

Note: More answers to frequently asked questions (FAQ) can be found on our FAQ page.

NEW PATIENTS

When you or your physician calls for an appointment, the phone attendant will collect as much information as possible at that time.  In order for our physicians to provide the very best care, we will ask that you fill out several forms before your first visit.  You can do this at the appointment or print off the forms, complete them and bring them with you to your first appointment.

  • Patient Registration Form & Privacy Notice Acknowledgement

  • Health History

  • Accident Information Form

  • Financial Policy (Read only. Don't need to bring to visit)

Please read through the Privacy Notice posted on this website (available on this page for printing) and complete the acknowledgement form (also on this page) stating you have received the Notice.

 

PLEASE NOTE: SCREEN PROMPTS THAT MIGHT APPEAR

 

Prompt #1: Password Prompt

Upon opening a form or exiting this page you may receive a prompt for a login or password. Simply hit "cancel" or exit without inputting any information.  This prompt is a function of your browser's unique settings and is not functional.  If you were trying to open the form when the prompt appeared, it should then open in Microsoft Word or Adobe Acrobat as normal.

 

Prompt #2: Save File Prompt

You should not make any changes to any form.  However, if you inadvertently make changes to the opened file, a dialog box may appear that states: "This document has been modified. Do you want to save changes?"  Simply exit the document file by clicking "no". Only print the original forms.

 

If you have trouble opening Acrobat (.pdf) files, you can download the reader for free here:

 

 


Patient Registration Form & Privacy Notices Acknowledgement


 Open Document File Now

Instructions: This is an Adobe Acrobat (.pdf) file.  Open the file, print it, and fill it out PRIOR to your visit.  This will speed up your visit.
   
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Privacy Notice


 Open Document File Now

Instructions: This is an Adobe Acrobat (.pdf) file.  Open the file, print and read it out PRIOR to your visit.  Then open the Acknowledgement Form below, print it, and sign it.  Bring the acknowledgement only to your first visit (not the Notice itself).
   
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Health History Form



 Open Document File Now

Instructions: This is an Adobe Acrobat (.pdf) file.  Open the file, print it, and fill it out PRIOR to your visit.  This will speed up your visit.
   
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Accident Information Form



 Open Document File Now

Instructions: This is an Adobe Acrobat (.pdf) file. Open the file, print it, and fill it out PRIOR to your visit.  This will speed up your visit.
   
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Financial Policy Form



 Open Document File Now

Instructions: This is an Adobe Acrobat (.pdf) file. Open the file, print it, and fill it out PRIOR to your visit.  This will speed up your visit.
   
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