Wichita Surgical Specialists Patient Forms

Current Patients

Thank you for choosing Wichita Surgical Specialists as your surgical care provider. Ensuring you receive quality surgical care is our first priority. We appreciate the feedback you can provide us so we can continue to serve you well.

Patient Feedback Form

First Time Patients

When you come in for your first visit to Wichita Surgical Specialists, you will need to complete forms regarding your medical history and insurance information. You can save time by printing off the forms below, completing them at home and bringing them to the office at the time of your appointment.

For All New Patients:

Release of Information Form

Medical History

If your appointment is with a surgeon listed below, please complete these secondary forms:

Dr. Alex Ammar:
Vascular Consultation Form (complete page 1 only)

Dr. Robert Bingaman:
Vein Care Specialists Health History Form

Dr. Therese Cusick:
Breast Care Specialists Health History Form

Dr. Gary Jost:
Vein Care Specialists Health History Form

Dr. Kimberly Molik:
Pediatric History and Physical Form

Dr. Nazih Moufarrij:
New Patient Information Questionnaire

Dr. Jacqueline Osland:
Breast Care Specialists Health History Form

Dr. Jason Woolard:
Vein Care Specialists Health History Form