Patient Forms

Patient Registration Forms

One Time Authorization
Insurance and Billing Information
Patient Medical Questionnaire
Acknowledgement of Notice of Privacy Practices

Protected Health Information

Notice of Privacy Practices
Authorization for Release or to Request Medical Information
Letter of Privacy Practices

Automobile Accident / Workers Compensation

Auto Accident Form
Workers Compensation Form

Forms for Appointments

Review of Systems – Please download and complete this form prior to your Complete Physical (also known as the “Annual Physical” or “Annual Check-up”
Consent to Treatment of Minors – Please download and complete this form if someone other than a parent will bring your child to the office for the appointments.

Colonoscopy Forms

If your doctor has recommended that you have a Colonoscopy by Dr. Steve Davis, please:
• Read the Letter to Patient and the Information/Consent Forms
• Download and sign the Information/Consent Form
• Download and complete the Health Questionnaire
• Return the signed Information /Consent Form & the completed Health Questionnaire to our office by mail or fax (316-858-5849)
• We will review your information and then contact you by phone to schedule the procedure.

Once your procedure is scheduled, you will receive Instructions for the Procedure and Bowel Prep Instructions. These forms are available below if you should misplace them:
• Instructions for Procedure
• Miralax/Gatorade Bowel Prep
• Magnesium Citrate Bowel Prep
• Osmoprep Prep
• GoLytely/CoLyte Bowel Prep

NOTE: You will perform only one bowel prep form from the list above as recommended by your doctor. You will NOT perform any combination of these bowel preps!

Advanced Directives Information & Forms

NOTE: You should not complete any of these forms until you have consulted with both your family and your doctor, and possibly an attorney. Examples of Advanced Directives are provided below for your convenience.

Living Will – This form allows you to tell your doctors what to do if you are on life support with no hope of recovery and there is no one else to tell the doctor about your wishes

Durable Power of Attorney for Health Care Decisions (a.k.a. DPOA) – This form allows you to grant power to one person to make medical decisions on your behalf if you are not able to do so for yourself

• Do Not Resuscitate (a.k.a. DNR) – If you stop breathing or your heart stops pumping blood and you do NOT want to have full life-saving measures taken by paramedics, nurses, doctors and other health care personal, then complete this form. This is usually only appropriate for people in poor health and near the end of life.

Other Forms

Kansas Pre-Participation Form (PPE FORM)
• Disable Parking Form
• KCI Form