Patient Forms
Patient Demographics: a link has been sent to you and is valid for 72 hours.
If your child will coming with someone besides their parent or legal guardian, please click on the form below, complete it online and submit it securely to our office:
- Child Treatment Authorization (Treatment Consent for Third Party Bringing Child)
Information listed below are referenced in the patient forms and can be printed for your file. Thank you.
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