Click below on each form for the following:
Bone Density Form (PDF)
This includes the instructions for patient preparation, procedure of the test, and a questionnaire that should be completed prior to arrival.
Consent for Minors (PDF)
This form provides consent for treatment of minors with permission by the parent and/or legal guardian.
Daycare Physical (PDF)
This form is approved by the Kansas Department for Health and Environment and is required for all children in child care facilities. Please print and fill out patient portion prior to appointment.
HIPPA Policy (PDF)
This is Notice of Privacy Practice for Clay Center Family Physicians. We are committed to protecting the confidentiality of our records containing information about you.
Health Questionnaire Form (PDF)
This is a questionnaire about your health and any family history of illness. It also covers immunizations, allergies and current medications.
Patient Registration Form (PDF)
This form covers general patient information such as Name, Date of Birth, Address, Employment, Insurance, Emergency Contact and Responsible Party.
Patient Injury Form (PDF)
This form will provide description of the date of injury/accident, place injury occured, how it happened and also if it will be Auto Insurance or Work Comp related.
Payment Policy (PDF)
The payment policy explains how patients with or without insurance must pay for their services provided by Clay Center Family Physicians
Permission to Disclose Information (PDF)
This disclosure pertains to the Authorization of Medical Treatment, Disclosure of Information, Assignment of Insurance Benefits, Precertification Policy, Financial Responsibility, Release of Protected Health Information, and Acknowledgement of Privacy Practices and Payment Policy.
Sport Physical Form (PDF)
This is the current, KSHSAA approved sport physical form. Please print this and complete patient portion before appointment.
Student Health Assessment Forms
Click below for each form>>