Patient Forms

Complete your paperwork before your visit to save time

To help us serve you better and reduce wait times at your first appointment, please complete the appropriate forms below before arriving at our clinic. All forms can be filled out and submitted online.

New Patient Intake Form

New Patients

Required for all new patients. Includes health history, current complaints, and insurance information.

Open Form

Auto Accident Intake Form

Auto Accident

For patients seeking care following an automobile accident. Includes accident details and insurance information.

Open Form

HIPAA Authorization Form

Required

Authorization for release of health information. Required for insurance billing and third-party communications.

Open Form

Medicare ABN

Required

Advance Beneficiary Notice of Noncoverage for Medicare patients. Required before receiving services Medicare may not cover.

Open Form

If you have questions about which forms to complete, please call our office at (316) 636-5550 and our staff will be happy to assist you.

(316) 636-5550

	(E)	(W)	(ANT)
Mon	9a–1:30p, 3p–6p	9a–1:30p, 3p–6p	—
Tue	—	10a–1:30p, 3p–6p	—
Wed	3p–6p	9a–1:30p	9a–12p
Thu	—	3p–6p	—
Fri	9a–1:30p, 3p–6p	—	—