Patient Forms
COVID-19 Clinic Policies:
– Additional siblings are NOT allowed to attend appointments
– Masks are mandatory for all persons over age 3 who enter our facilities
– A maximum of TWO legal guardians are permitted to attend appointments
Failure to comply with any of these policies will result in cancellation of the appointment upon arrival.
Thank you for your cooperation and understanding.
Please complete the required paperwork prior to your appointment- thank you!
New patients:
Health History Form (if you DO have a Patient Portal account)
Health History Form (if you do NOT have a Patient Portal account)
Patient Demographic Form
HIPAA Privacy Consent
Virtual Visit Consent Form
(Only required for those whose first appointment with us is virtual)
Returning patients:
For returning patients, the following are only required if your most recent appointment was OVER 3 years ago.
Health History Form (if you DO have a Patient Portal account)
Health History Form – (if you do NOT have a Patient Portal account)
Patient Demographic Form
Specialty Forms
Only required if specifically instructed to by our staff when the appointment was scheduled
Prenatal Health History Form
Neurogenic Bladder Questionnaire
Legal Forms and Record Requests:
Temporary Authorization 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.
Temporary Consent to Accompany a Minor Form
Patient 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.
18+ Medical Consent Form
Release of Medical Records:
If you would like to release patient records
from Pediatric Surgical Associates
to a different clinic, provider or person,
please fill out the form below.
If you would like to release patient records
to Pediatric Surgical Associates
from a different clinic, provider or person,
please fill out the form below.
Legal Guardianship Documentation
To send our office proof of legal guardianship, custody, adoption documents, or foster care documentation, 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