Patient Information Sheet - 18 years and over
State laws vary on fees for transfer of records. Most allow for free transfer to another physician for medical care continuation.
This form is for transfer of records to another physician. We do not charge to send to another physician, but do charge for personal uses. In Kansas there is a $18.97 labor fee, plus $0.63 per page for the first 250 pages, and $0.45 per page for additional pages. Kansas charges are based on Kansas Statute No. 65-4971.
To participate in sports at the high school level, Kansas law requires a physical be done after May 1st and before the start of the season. We require that the first page MUST be completed by parent or student before the provider can sign the form!
All youth participating in CYO sports will be required to use the Kansas High School Pre-Participation Health Form. Please fill out page 1 prior to your office visit. It is detailed and takes time to fill out. We cannot sign the form without your section completed.
When your child has a well visit exam we can upload this completed form to the portal for you to print as needed for the following year. This form is used for all licensed daycares, preschools, and state supported camps. Families should fill in the first page; we can provide a vaccine statement and the third page. Download a copy of the Kansas Child Care form.
Food Allergy or Asthma Action Plan: If your child has a food allergy or asthma, please ask that we give a new Action Plan each year for his or her school.
Missouri High School Sports Form:
Missouri state required forms for participation in sports can be found on the Missouri State High School Activities Association website.
School Physical Forms:
When your child has a physical we can put a copy of the school physical in the portal for you to print as needed.