Forms
This page is divided into three parts:
- Office forms for use at Pediatric Partners.
- You can return completed forms to our office by bringing them in, secure messaging them to office@pediatricpartnerskc.com, or taking a picture and sending them by portal message.
- Forms may incur fees if they are not completed at the time of a visit.
- Forms will be returned within 5 business days with a rush fee of $25 in addition to the form fee for forms required within 48 hours.
- ALL patient sections MUST BE COMPLETE before we can complete our sections.
- Printable health forms for school, scouting, and more
- Behavioral Health forms that may be used when not available in our Phreesia system (most can be sent by text so no need to print!)
See Pediatric Symptom Checklist for the survey in other languages as needed.
Office Forms
Medical Surgical History Review
For New Patients
Transfer of Records TO Pediatric Partners for New Patients
State laws vary on fees for transfer of records. Most allow for free transfer to another physician for medical care continuation.
Transfer of Records FROM Pediatric Partners
This form is for transfer of records to another physician. We do not charge to send to another physician. There may be charges if records are requested for personal use. Most patients can find the information they require in their portal.
Photo-Release-Form-for-social-media-consent
Consent for Pediatric Partners to use personal photos or videos
Health Forms
Kansas High School Pre-Participation Health Form
To participate in sports at the high school level, Kansas law requires a physical be done after April 1st (new 2025!) and before the start of the season. We require that the appropriate information is filled in by the parent/student before we will complete our sections. Forms will be available at check-in or you can use the form linked.
Childcare Forms: You DO NOT need to print these. This is for informational purposes only. Our EHR will populate this form and we can upload it to your portal after each well visit. This completed form can be printed directly from your child's portal when needed.
Missouri State High School Activities Form 2023
Missouri only requires this page to be completed. Please complete the top portion and bring it to your well visit. We will require you to fill out the Kansas form if you do not include the similar pages on the Missouri form, available on the MSHSA website. The questions help us evaluate your overall risk factors and Missouri does not require those pages of the form to be returned to the school.
Food Allergy or Asthma Action Plan
If your child has a food allergy or asthma, please ask that we give a new Action Plan each year for his or her school.
School Physical Forms
When your child has a physical we can put a copy of the school physical in the portal for you to print as needed.
Behavioral Health Forms
Diagnostic tool for parents and other caregivers
To follow symptoms after the diagnosis is made
Diagnostic tool for teachers
Follow up form for teachers to help track symptoms
ADHD self report for teens and adults
ADHD self reports for older teens and adults
Edinburgh Postnatal Depression Scale
Depression screen for new parents
7-question anxiety screen
Autism screening
Pediatric-Symptom-Checklist-Youth-report-(PSC-Y)
Pediatric Symptom Checklist (Youth report, ages 11+) to screen for mood and focus concerns.
Pediatric-Symptom-Checklist-Parent-Report-(PSC)
Pediatric Symptom Checklist (parent report)
SCARED Anxiety Screen (child to complete)
Office Info
