Patient Forms

Current Patients

Thank you for choosing Wichita Surgical Specialists as your surgical care provider. Ensuring you receive quality surgical care is our first priority. We appreciate the feedback you can provide us so we can continue to serve you well.

PATIENT FEEDBACK FORM

First Time Patients

When you come in for your first visit to Wichita Surgical Specialists, you will need to complete forms regarding your medical history and insurance information. You can save time by printing off the forms below, completing them at home and bringing them to the office at the time of your appointment.

For All New Patients:

Release of Information Form

MEDICAL HISTORY AND REVIEW OF SYSTEM

If your appointment is with a surgeon listed below, please complete these secondary forms:

Dr. Therese Cusick and Dr. Samantha Beck:

Breast Care Specialists Health History Form

Dr. Thomas Resch at Vein Care Specialists:

VEIN CARE SPECIALISTS HEALTH HISTORY FORM

Colonoscopy Patients:

SCREENING CE GUIDE

If you are needing to schedule a colonoscopy with a surgeon listed below, please complete these forms:

Dr. Mark Niederee and Dr. Austin George:
COLONOSCOPY FORMS

Dr. Michael Porter and Dr. Lindsay Strader:
COLONOSCOPY FORMS

If you have a colonoscopy scheduled with a surgeon listed below, please follow the prep instructions:

Dr. Samantha Beck:
COLONOSCOPY PREP INSTRUCTIONS

Dr. Austin George:
COLONOSCOPY SPLIT PREP INSTRUCTIONS

Dr. Jeremy Howes, Dr. Brent Lancaster and Dr. Aaron Nilhas:
COLONOSCOPY PREP INSTRUCTIONS

Dr. Brady Werth:
COLONOSCOPY SPLIT PREP INSTRUCTIONS

Dr. Jerry Gaston:

COLONOSCOPY PREP INSTRUCTIONS

COLONOSCOPY PREP INSTRUCTIONS – RIDGEWOOD PATIENTS

COLONOSCOPY PREP INSTRUCTIONS – ST. TERESA PATIENTS

Medical Record Request

To request a copy of your medical records, please complete the form and fax to 316-494-6895.

Medical Record Fee Schedule

RECORD REQUEST FORM

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