Clinic Forms
Important note: We are moving to a new electronic health record system, and this page will no longer available after February 28, 2026. Thank you for your understanding.
The following are forms that your provider may request you complete.
- Clinic Forms:
- Abdominal Pain Clinic Evaluation Questionnaire
- ADHD Preschool Rating Scale
- Adolescent (self-reported) Outcomes Questionnaire
- Asthma Control Forms
- Bridge Screen
- Comprehensive Colorectal Center
- Connecting to Resources
- Diabetes Survey 1.0
- Depression Anxiety Stress Score-21 (DASS-21)
- Early Onset Scoliosis (EOS) Questionnaire
- EoE Evaluation
- Edinburgh Postnatal Depression Scale
- Epilepsy Questionnaire
- Feeding Therapy Questionnaire
- Food Insecurity
- Functional Disability Inventory (FDI)
- Lead Risk Assessment Guide
- Medical Contact Lens Order Form
- Metal Adverse Reaction Screening
- Neurological Disorders Depression Inventory-Epilepsy-Youth
- Neuropsychological Evaluation History Questionnaire
- Obstetric Patient Pre-Anesthesia Assessment
- PHQ2
- PROMIS Parent Proxy Global Health 7
- PROMIS Pediatric Global Health 7
- PROMIS Stress Experiences Questionnaire
- Review of Systems
- SRS 22
- Sleep Clinic Questionnaires
- Sport Concussion Assessment Tool
- Swallow Study Parent Screening Survey
- Transition Readiness Surveys
- Vancouver Symptom Scale
- Vanderbilt Follow Up
- Vanderbilt Parent Evaluation
- Access Rep Forms:
- Acknowledgement of Receipt of Information
- Informed Consent for Medical and Dental Treatment
- Electronic Health Information Exchange Rights
- Notice of Non-Covered Services
- Notice of Privacy Practices
- Objection to Being Listed in Patient Directory
- Off Campus Coinsurance Notification to TriCare Patients
- Patient Portal eConsent
- Patient Rights, Rules and Responsibilities
- Plain Language Summary of Children’s Mercy Financial Assistance Policy
- Preregistration Outgoing Letter
- Preregistration SDS Outgoing Letter
- Consents/HIM Forms:
- Authorization to Disclose Information to Community Resources
- Children’s Mercy COVID-19 Vaccine Consent Form
- Consent for Flu Vaccine
- Immunization Screening Consent Form
- Informed Consent for Therapeutic Apheresis
- Informed Consent for Medical and Dental Treatment
- HIM-Release of Medical Information
- Informed Consent for Surgery or Other Procedures
- Patient Portal eConsent
- Telemedicine Consent Form