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.
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:
MEDICAL HISTORY AND REVIEW OF SYSTEM
If your appointment is with a surgeon listed below, please complete these secondary forms:
Dr. Therese Cusick and Dr. Samantha Beck:
Breast Care Specialists Health History Form
Dr. Nazih Moufarrij:
New Patient Information Questionnaire
Dr. Thomas Resch at Vein Care Specialists:
VEIN CARE SPECIALISTS HEALTH HISTORY FORM
Colonoscopy Patients:
If you are needing to schedule a colonoscopy with a surgeon listed below, please complete these forms:
Dr. Mark Niederee and Dr. Austin George:
COLONOSCOPY FORMS
Dr. Michael Porter and Dr. Lindsay Strader:
COLONOSCOPY FORMS
If you have a colonoscopy scheduled with a surgeon listed below, please follow the prep instructions:
Dr. Samantha Beck:
COLONOSCOPY PREP INSTRUCTIONS
Dr. Jeremy Howes, Dr. Brent Lancaster, Dr. Aaron Nilhas, and Dr. Brady Werth:
COLONOSCOPY PREP INSTRUCTIONS
Medical Record Request
To request a copy of your medical records, please complete the form and fax to 316-494-6895.
Privacy Notice
View or print our privacy policy here.