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Patient Forms

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 complete the required paperwork prior to your appointment- thank you!


New patients:

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

HIPAA Privacy Consent

Virtual Visit Consent Form

(Only required for those whose first appointment with us is virtual)


Returning patients:

For returning patients, the following are only required if your most recent appointment was OVER 3 years ago.

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


Specialty Forms

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

Prenatal Health History Form

Neurogenic Bladder Questionnaire


Legal Forms and Record Requests:


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

Patient 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.

18+ Medical Consent 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.

Release of Medical Records

Printable PDF – 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.

Release of Medical Records

Printable – Release of Medical Records


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


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
Contact Us
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