Leawood Pediatric Forms

There is no charge for forms (except FMLA forms - see below) completed at the time of your child's well visit .

Charges for forms completed outside of a well visit or FMLA paperwork:
$10 - Form will be completed in 7-10 business days from date of payment
$25 - Form will be completed within 48 hours (additional "Rush Fee" of $15) from date of payment
$40 - FMLA & other extensive paperwork (completed in 7-10 business days) from date of payment

These charges cover the staff and physician time to complete this paperwork.
Please see our financial policy for details.

If you need forms completed for your child outside of a well visit, you may drop off the form at our front desk, mail (5401 College Boulevard Suite 101 Leawood, KS 66211), e-mail (medicalrecords@leawoodpediatrics.com) or fax (913-948-9128) to our office. If you mail/e-mail/fax the form to our office, your card on file will be charged the forms fee unless you make other arrangements with our front desk staff.

Please complete the Paperwork Request Form and include with your documents to ensure timely return & accurate processing of your paperwork. 

ADHD

• Parent Assessment Scale
• Teacher Assessment Scale
• Parent Follow Up
• Teacher Follow Up
   

Adolescent Well Visits

Here is the appropriate pre-visit questionnaire for you child's upcoming appointment and some helpful information on you child.  Please fill this out prior to your child's appointment.  This is a fillable form, yay! :) 

• 11-14 Please click here for the Pre-Visit Questionnaire on your 11-14 year old
• 15-17 Please click here for the Pre-Visit Questionnaire on y our 15-17 year old
• 18-21 Please click here for the Pre-Visit Questionnaire on your 18-21 year old   

Immunization Consents

• Vaccine Consent Form
• 2016-2017 Influenza Parent FAQs

Medical Records

• Medical Records Release Form
• Minor Delegation Form
• Adult Delegation Form

• New Patient Registration Form
• Notice of Privacy Practice
• Paperwork Request Form