Patient Forms
Save time at check-in and complete your paperwork online prior to your appointment!
New Patients or Returning Patients Last Seen Over 3 Years Ago
Please complete the following forms prior to your appointment:
1. General Consent Form
2. Patient Demographic Form
* If you are a returning patient and have had any recent changes to your address, phone number, email, or primary care provider, you can update this information yourself in your Patient Portal account from the Menu option: “My Account”
3. Health History Form (if you DO have a Patient Portal account. Navigate to “Questionnaires on the left menu – Health History Form)
Health History Form (if you do NOT have a Patient Portal account)
*You may also complete the Health History Form through the Healow App
TELEHEALTH APPOINTMENTS: If your child’s first appointment with us is a telehealth appointment, you must complete all of the above forms by 3:00 PM on the day before the appointment. If the forms are not submitted by that time, the appointment will be canceled.
Medical Records Request & Other Legal Forms
Release of Medical Records:
If you would like to release patient records from Pediatric Surgical Associates to a another clinic, provider or individual, please complete the form below. You will then be contacted by our medical records department.
Release of Medical Records – Submit Online
If you would like to release patient records to Pediatric Surgical Associates from a another clinic, provider or individual, please complete the form below.
Release of Medical Records – Submit Online
Temporary Consent to Accompany a Minor
If someone other than the patient’s legal parent or guardian will be bringing the patient to the appointment,
this form must be completed and signed by the child’s LEGAL guardian prior to the appointment.
Please follow the link to complete.
18+ Medical Consent Form
According to Minnesota law and the HIPPA privacy rule, when patients turn 18 years old they are considered adults, and parents and guardians can no longer access the patient’s medical information without the child’s written consent. Please have your child fill out this consent form if they would like to provide consent for you (or anyone else) to view their medical record.
Legal Guardianship Documentation
To send our office proof of legal guardianship, custody, adoption documents, foster care documentation, or related forms, please send using one of these options:
Email: Forms@pediatricsurgical.com
Fax: 952-835-9443
or mail to the following address:
Pediatric Surgical Associates
2530 Chicago Ave. S. Suite 550
Minneapolis, MN 55408
Specialty Forms
Only required if specifically instructed to by our staff when the appointment was scheduled