St. Louis Medical Clinic St. Louis Medical Clinic

(314) 432-1111 Patient Portal

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For payments, please call the office.
7:30am to 4:30pm
Monday through Friday

314.432.1111

Thank you.

Authorization to Release Medical Records

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Authorization to Release Medical Records Form

Authorization to Obtain Medical Records

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Authorization to Obtain Medical Records Form

Patient Demographic Information

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Patient Demographic Information Form

Patient Health Questionnaire

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Patient Health Questionnaire Form

Consent to Treat and Financial Policy

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Consent to Treat and Financial Policy Form

Notice of Privacy Practice, Acknowledgement & Authorization

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Notice of Privacy Practice, Acknowledgement & Authorization Form

Patient Information Form

  1. Click the link below to download a fillable PDF form. You may type directly into the form.
  2. Then, print the form and bring it with you to your appointment.
  3. Or, you may save the form to your computer and email it to NKoeller@StLMedClinic.com.

Download Fillable Patient Information Form