Patient Information Sheet - 18 years and over
To be updated by each family yearly
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 appropriate information is filled in by the parent/student before we will complete our sections. (The pages we complete are NOT included here because they are generated by our EHR. This saves printing waste!)
Childcare Forms: You DO NOT need to print these. This is for informational purposes only.
Our EHR will populate this form and we can upload it to your portal after each well visit. This completed form can be printed directly from your child's portal when needed.
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.