Clinic Forms
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
- COVID-19 Saliva Testing Study
- Immunization Screening Consent Form
- Informed Consent for Therapeutic Apheresis
- Informed Consent for Medical and Dental Treatment
- HIM Behavioral Health-Release of Information
- HIM-Release of Medical Information
- Informed Consent for Surgery or Other Procedures
- Patient Portal eConsent
- Telemedicine Consent Form
- Therapeutic Apheresis Consent