Save time at check-in and complete your paperwork online prior to your appointment!
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)
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
Medical Records Request & Other Legal Forms
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.
If you would like to release patient records to Pediatric Surgical Associates from a another clinic, provider or individual, please complete the form below.
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.
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.
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:
or mail to the following address:
Pediatric Surgical Associates
2530 Chicago Ave. S. Suite 550
Minneapolis, MN 55408