Patient Forms
Additional Reminder:
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 follow the links below to to complete your paperwork.
Forms must be submitted no later than two days prior to the appointment.
NEW patients:
Health History Form (preferred method)
Alternate link
Patient Demographic Form
HIPAA Privacy Consent
Virtual Visit Consent Form
*Telehealth patients only*
RETURNING patients:
*Required only if most recent appointment was over three years ago
Health History Form (preferred method)
Alternate link
PRENATAL patients:
Prenatal Health History Form
Legal Guardianship Documentation
If you need to send our office documentation of legal guardianship, 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
Additional Forms
If applicable
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
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.