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

We're Delighted You Want To Make An Appointment!

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

​   Questions?

    Our New Patient Agreement can answer many of your questions. Please review this form before making an appointment.

 

   Ready to Get Started? Just follow the 3 steps below.

Step 1 - Complete and Print These Paper Forms

 

 

New Patient Agreement Please read and sign the last page. Bring the last page to your first visit.

Step 2 - Complete This Online Intake Form

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.

 

Step 3 - Complete and Print These Paper Forms If They Apply to You

 

Holistic Heart Disease Risk Assessment For all new patients age 40 or older to complete and for anyone interested in a more holistic heart disease risk assessment. This is a fillable PDF. Download and save it to your computer first, then complete and save it. Bring to your first visit or save and email to us in advance of your appointment.

Biochemical Imbalance Screening Test (BIST) Please complete if your are concerned about mood, cognitive performance, behavior, mental health, neurodegenerative issues or are interested in the Walsh Research Institute protocol. It takes about 20 minutes to complete.

​Chronic Pain and Headache Form Please complete and bring to you first visit 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. Please bring to your first visit.

​Children's History Form Please complete if the patient is a child and bring to your first visit.