Forms

New Patient Forms: please download and fill out the new patient forms prior to your first visit.

 

Telemedicine (Virtual Visit) Consent Form
Telemedicine Consent Form.pdf
Adobe Acrobat document [816.6 KB]
Privacy Notice
Privacy Notice.pdf
Adobe Acrobat document [275.4 KB]
Medical Records Release Form
Medical_Records Release Form.pdf
Adobe Acrobat document [1.3 MB]
Release of Information Form
Release of Information to a family membe[...]
Adobe Acrobat document [218.0 KB]
Patient Demographic Form
PatientDemographics.pdf
Adobe Acrobat document [23.9 MB]
Past Medical History
PatientMedicalHistory.pdf
Adobe Acrobat document [16.1 MB]
Payment Policy
PaymentPolicy.pdf
Adobe Acrobat document [24.3 MB]

For physicals and other visit forms please select the appropriate sub-pages to the left.

Please Note: It is not okay to copy and/or reproduce any form from this site for any use other than that for which it was originally intended.

Click for more information.
(Virtual Visits)
(Patient Portal)
(Pay Bill)

Where to Find Us

606 N Mulberry Rd

Derby, KS, 67037

 

Phone: (316)788-3787

Fax: (316)788-2618

 

Clinic Hours

Mon     8am - 5:00pm
Tues   8am - 5:30pm
Wed   8am - 6:30pm
Thurs  

8am - 5:00pm

Fri   8am - 3:30pm
Sat  

Closed

*Saturday hours available

for Virtual Visits/Telemedicine.

 

Hours may vary based on provider availability. Hours subject to change. Please call for scheduling. 

 

(COVID-19 may affect hours.)

Lab Hours

Mon     8am - 1pm
Tues   12pm - 4pm
Wed   8am - 1pm
Thurs  

12pm - 4pm

Fri   8am - 1pm
Sat  

Closed

(COVID-19 may affect hours.)

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