5501 NW 62nd Terrace, Suite 100
Kansas City, MO 64151
(816) 842-1974 - fax
(816) 842-4440 - phone

Partnering for Excellence in Healthcare

Patient Forms

To ensure that we have all of your current demographic and health information, we have included the following forms for you to complete. To view the form, please click on the form name below, complete it online, print and bring it with you to your next appointment.

We appreciate that time that you take to compete these documents in advance. By decreasing the amount of paperwork that you need to fill out when you arrive at our office, we are able to start your visit with your provider sooner.

New Patient Forms

FormIcon-patient information
Patient Information
FormIcon-patient history
Patient History
FormIcon-record release
Medical Record Release

Complete Physical Forms

FormIcon-patient instructions
Patient Instructions
FormIcon-review of systems
Review of Systems
FormIcon-well woman exam
Well Woman Exams

Diabetes Management Forms

The following forms are presented in Acrobat Reader® format. Please click on the desired icon below, print and complete the forms and bring with you to your next appointment

Goals for Patients with Diabetes
Goals For Patients with Diabetes
Weekly Blood Sugar Log
Weekly Blood Sugar Log
Daily Food Intake Record
Daily Food Intake Record
Cholesterol Information
Cholesterol Information

Policy Forms

Financial Policy
Financial Policy
Vaccine Policy
Vaccine Policy

Clay Platte Family Medicine Clinic

5501 NW 62nd Terrace  •  Kansas City, Missouri 64151  •  (816) 842-4440