St. Louis Medical Clinic St. Louis Medical Clinic

PH: (314) 432-1111  Fax: 314.432.3629 Patient Portal


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Patient Forms

Before your appointment with us, quickly and conveniently access patient forms from our practice.

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.

Adult Patient Forms
Pediatric Patient Forms

 

Scan or Click to Check In For Your Appointment

Pediatric Patient Medical History

  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 Forms@StLMedClinic.com

Please Select Your Preferred Language

       

Pediatric 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 Forms@StLMedClinic.com

Please Select Your Preferred Language

       

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 Forms@StLMedClinic.com.

Please Select Your Preferred Language

       

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 Forms@StLMedClinic.com

Please Select Your Preferred Language

       

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 Forms@StLMedClinic.com

Please Select Your Preferred Language