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Patient Forms

PLEASE NOTE: Due to COVID-19

We allow only TWO parents/guardian, and no siblings to accompany the patient to the appointment. Failure to adhere to this policy may result in cancellation or postponement of the appointment.

Thank you.

 

Please complete the following forms online prior to your appointment.

 

Patient Information & Demographic Form – New Patients or those not seen in previous 12 months

Submit Online

(Printable PDF)

 

HIPAA Privacy Consent Form – New Patients

Submit Online

(Printable PDF)

 

Health History Form – For all new and returning pediatric patients

Submit Online

**Disregard if you have already completed through our Patient Portal

 

Prenatal Health History Form- For patients having a Prenatal consult

Submit Online

*Only use this form if your first appointment is a prenatal consult. If this applies to you, you do not need to complete the Health History Form listed above.

(Printable PDF)

 

Telehealth- Virtual Visit Consent Form

Virtual Visit Consent Form

 

 

Additional  Forms –  NOT REQUIRED unless otherwise informed by our staff

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.

Submit Online – Release of Medical Records

Print – Release of Medical Records

 

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.

Submit Online – Release of Medical Records

Print – Release of Medical Records

 

Temporary Authorization to Accompany a Minor 

Complete this form for temporary authorization by a patient’s legal guardian(s) for a non-custodial adult to accompany a minor to their appointment.

Submit Online – Temporary Consent to Accompany a Minor Form

Print- Temporary Consent to Accompany a Minor Form

 

 

 

To view the forms listed, you will need Adobe Reader.  Please bring your completed forms with you to our office at the time of your visit.

 

 

 


Pediatric Surgical Associates





Related Sites

Children's Hospitals and Clinics of Minnesota
American Urological Association
American Pediatric Surgical Association
American Academy of Pediatrics
Midwest Fetal Care Center
Gillette Children's Specialty Healthcare
Regions Hospital
Twin Cities Shriners Hospital
APSA Parent and Family Resource Center
Urology Care Foundation Patient Education

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