(316) 634-2000 - East Wichita | (316) 773-3100- West Wichita | (316) 719-2020 - Derby
(316) 634-2000 - East Wichita | (316) 773-3100- West Wichita | (316) 719-2020 - Derby

Patient Forms

Thank you for choosing Mid Kansas Pediatric Associates as your child's medical home, where we always provide a comfortable, caring environment so our patients and their families can feel at ease. We've included helpful items on this page to ensure you and your child's first trip to our office is productive, stress-free and enjoyable.

Our Mission

Our practice is working together to build life-long relationships between our staff and our patients by consistently providing our patients with compassion, excellence and value. To fulfill this mission, we are committed to:

  • Improving the lives of the children we serve by providing quality care in a child-centered environment.
  • Listening to our young patients and their families who we are privileged to serve.
  • Guiding our patients along a path of optimal health and wellness.
  • Continually pursuing excellence at all levels through continuing education.

If you're preparing for your child's first visit, you can do a few things to help expedite the appointment. Please provide the following information when you arrive for your visit:

  • Insurance cards
  • Complete immunization records
  • Medical records from your previous pediatrician

Patient Forms

We are happy to provide our office forms for convenient download on your home computer. Please print and complete the forms below, and bring them with you to your child's first appointment. Questions about which forms you need? Please call our office and our courteous staff will assist you in preparing for your child's first visit.

  • Patient Information
    Please print and fill out prior to your first visit, or if requested.
    Click here to open form
  • Medical Records Release Form
    Please print and fill out prior to obtaining records from our office. You may also use this form to request records from your previous physician to our office.
    Click here to open form
  • Appointment of Agent
    This form allows others (i.e. grandparents, nanny, etc.) to bring your child to our office.
    Click here to open form
  • Emergency Care Authorization
    This form is helpful when parents are going out of town and leaving their children with another caretaker. This form is accepted at our office and hospitals in case of emergency while the parents are gone. It is also helpful to leave a copy of your insurance card with the caretaker.
    Click here to open form
  • High School Sports Form
    This form must be completed prior to starting high school sports. The child must have a physical exam after May 1st. Parents need to complete the first page then bring the form to the office to be completed.
    Click here to open form

Adobe Acrobat Reader DownloadIn order to view or print these forms, you will need Adobe Acrobat Reader installed. Click here to download it.

The Initial Visit

Our compassionate city pediatricians do whatever it takes to make every visit to our office a pleasant, relaxed experience. With all of the important information about our practice available on our website, you can feel confident that you and child are well-prepared for your first appointment. We also invite you to review our staff page in order to get to know our doctors and staff. We look forward to meeting you.

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