Patient Forms

1. General Consent Form

2. Patient Demographic Form

3. Health History Form (if you DO have a Patient Portal account)

Health History Form (if you do NOT have a Patient Portal account)

IMPORTANT: 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.

If your child’s last appointment with us was more than 3 years ago, please complete the Health History Form, and the Patient Demographic Forms below

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

If your child been seen before at our clinic, but the upcoming appointment is your first telehealth appointment, please complete the Virtual Visit Consent Form below

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

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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.

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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.

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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

Only required if specifically instructed to by our staff when the appointment was scheduled

Prenatal Health History Form

Neurogenic Bladder Questionnaire