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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 this before the first visit

  • ​General Questionnaire:  For all new patients to complete  

  • Beyond Cholesterol Assessment: For all adult new patients to complete and for anyone interested in a more holistic heart disease risk assessment 

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

  • ​Chronic Pain and Headache Form: Please complete if pain is the 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


Click this icon for our

Information and Policies Form




Click this icon for our

Children's History Form


    Click this icon for our  Chronic Pain/Headache Form


Click this icon for our

       Request for Information Form  


 Click this icon for our

Medicare Form


Click this icon for our

Questionnare Form



click this icon for our Beyond

        Cholesterol Assessment

Copyright © 2019 HealthSpan

All Rights Reserved


1900 West 75th Street, Suite 250

Prairie Village, KS  66208

V.                            F. 913-642-1901