Clinic Patient Registration Form

Welcome to Olathe Medical Services. We are pleased that you have chosen one of our clinics to provide care for you and your family. Your office visit is meant to be a pleasant experience, and we ask for your assistance in establishing a good medical relationship.

Proper patient registration is important. If this will be your first visit to our clinic, please fill out the Clinic Patient Registration Form below. It will take approximately 10 minutes to complete. You will not be able to stop and save your information, due to patient privacy practices, so make sure you allow adequate time to complete the form. If you have questions, please contact your clinic, or call 913-782-2974.

When you arrive at the clinic for your visit, you will check in at the front desk. Please have your current insurance card and photo ID available at check-in. Any applicable co-pay is also required at the time of check-in (as in accordance with insurance guidelines).

(*) Field Required.

Patient Information

Which clinic will you be visiting?*
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First Name*
Middle Initial
Last Name*
Home Phone*
Cell Phone
Work Phone

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Street Address
City
State
Zip Code
Referring Physician
Primary Care Physician
Patient Birth Date*
Patient Sex
Patient Marital Status
How did you hear about our clinic?
Other

Emergency Contact

Contact First Name
Contact Last Name
Relationship To Patient
Home Phone
Work Phone
Cell Phone

Optional Demographic Information

We would appreicate your joining our effort to ensure the provision of quality healthcare for all patients by telling us your racial/ethnic background. The choice to supply this information is voluntary.

Please choose the race with which you most closely identify




Please indicate Hispanic or Latino origin (Ethnicity)

What is your primary language?