The first three forms shown below may be filled out online and securely sent to our office prior to your first appointment.

The remaining forms will be downloaded as an Adobe Reader® form when you click the PDF icon. We ask that whenever possible, these forms be hand-carried to the office since we cannot guarantee the receipt of documents sent by mail.

New patients: please click the link above for new patient forms and other helpful information.

Established Patients

Health History Form
If you have been asked to complete a health history form
, please complete and submit this document.

Patient Demographics Form
For name or address changes
:
please complete and submit this form prior to your next appointment.

Receipt of Privacy Practices
To grant permission for certain individuals to have access
to records and discuss your care please complete and submit this form.


Click on the PDF icon for any form shown below to download an Adobe Reader® file of that form. If you don’t have Adobe Reader on your computer, please click here for a free download.

To view our privacy policy, please read this document.
Privacy Practices

If you need to request medical records or have records transferred, please complete and return this form.


Medical Records Release
To view our financial policy, please read this document.
Financial Policy


Johnson County OB/GYN Chartered  •  7440 W. Frontage Road  •  Merriam, Kansas 66203  •  913-236-6455