To save you time on the day of your first appointment, please click on the form below, complete it online and submit it securely to our office:
If your child will coming with someone besides their parent or legal guardian, please complete, print and bring to your next appointment:
- Child Treatment Authorization (Treatment Consent for Third Party Bringing Child)
Print the forms below, complete them, and bring them with you to your consultation. Thank you.
- Financial Policy
- Communication Authorization
- Notice of Privacy Practices Policy (for your review only)
- Acknowledgement of Receipt of Notice of Privacy Practices
Medical Release Authorization
Please complete the form below to authorize release of your child's medical information. Medical records sent to another provider for continuity of care do not have associated fees. This form must be complete, including the date and signature as we cannot process incomplete forms. Medical Record reproduction fees for personal use are listed below:
- $18.97 for base fee
- $0.63 per page
- $20.00 for CD of radiographs
Authorization Form for Release of Medical Records
Please sign, date and fax this form to 913-491-0547, or submit to our office by hand, by mail, or by scanning and emailing to This email address is being protected from spambots. You need JavaScript enabled to view it.