Patient Forms

Financial AgreementBelow are various forms available for downloading.

New Patient Forms:

Communication Forms:

Communication Request via phone

Medical Records Forms:

If you wish to fax medical record requests, please print the form, complete and fax to
913-338-1311.

Request to Amend Health Information
Medical Records Release Form 2 [from CPFCC to outside provider]
Medical Records Review/Receive Request Form [from CPFCC to patient]

Imaging Forms:

Dermatology Health History Forms:

Dermatology Medical History Questionnaire

Orthopaedic Forms/Handouts:

Pain Management Department Health History Forms:

Vaccine Information Statements

Note: If your child received Pediarix, they received DTaP, Polio and Hepatitis B in one injection.