Copyright © 2019 HealthSpan

All Rights Reserved

HealthSpan 

1900 West 75th Street, Suite 250

Prairie Village, KS  66208

V.                            F. 913-642-1901

913-642-1900

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Questionnaire pdf file

We're Delighted You Want To Make An Appointment!

You may contact one of our Patient Concierges at 913-642-1900 (voice) or by email

​   Questions?

    Our Information and Policies Form can answer many of your questions. Please review this form before making an appointment.

 

   Ready to get started? 

    Please review and complete the following forms and bring them to your first visit.  

​Information and Policies Please read and sign page 6 and bring to your first visit

Holistic Heart Disease Risk Assessment For all adult new patients to complete and for anyone interested in a more holistic heart disease risk assessment 

New Patient Medical History Intake  For all new patients to complete and submit. After completing the initial registration, please complete the intake form. Submit it as soon as possible to take advantage of our waiting list. Otherwise, submit it the day before your appointment at the latest so Dr. Klug can review it before your appointment. Please allow at least 60 minutes to complete.

 

​Chronic Pain and Headache Form Please complete if pain is a top reason for seeing Dr. Klug

​Request for Information Form This form allows Dr. Klug to request records from or send records to your other physicians. Please complete and send to our office if you want Dr. Klug to review past lab or other records at your appointment

​Medicare Private Contract Form Does the patient have Medicare? If so, the patient or patient's guardian must carefully read and sign this contract before Dr. Klug can see the patient

​Children's History Form Please complete if the patient is a child