Patient Forms

When did you last visit Pediatric Surgical Associates?

I am a new patient, no previous visit
I am a general surgery patient that has not been seen for 1-3 years
I am a urology patient that has not been seen for 1-3 years
I am a patient that has not been seen in 3+ years

 

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.

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.

 

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.