To save you time on the day of your first appointment, please print the forms below, complete them, and bring them with you to your consultation. Thank you.

• Financial Policy
• Patient Demographics
• Communication Authorization
• Patient Health History
• Notice of Privacy Practices Policy
• 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.