Patient Forms
To view the forms listed below, you will need to download Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.
Internal Medicine – Center for Health Care Forms and Policies
- Adult Patient Demographic
- Patient History (IM)
- Authorization for the Release of Protected Health Information
- Established Patient Self-Pay Agreement
- New Patient Self-Pay Agreement
- Acknowledgement of Policies
- Acknowledgement of Patient Rights and Responsibilities
- Consent to Communicate Electronically
- New Patient Outpatient Consent
- Financial Policy
- Notice of Non-Discrimination
- Notice of Privacy Practices
- Ku Wichita Internal Medicine Clinic Policies
Midtown Clinic Forms and Policies
- Adult Patient Demographic
- Patient History (MT)
- Authorization for the Release of Protected Health Information
- Established Patient Self-Pay Agreement
- New Patient Self-Pay Agreement
- Acknowledgement of Policies
- Acknowledgement of Patient Rights and Responsibilities
- Consent to Communicate Electronically
- New Patient Outpatient Consent
- Financial Policy
- Notice of Non-Discrimination
- Notice of Privacy Practices
- Ku Wichita Internal Medicine Clinic Policies
Functional Medicine