Forms
Bring printed forms to your scheduled appointment, or submit via fax (952-401-8242) or email (healthinformation@slpeds.com).
Questions? Call us!
Forms
- Release of Medical Information
- How to fill out Release of Medical Information form
- Authorization for Other Adults to Consent to Treatment
- Change of Guarantor
- Change of Guarantor (18 years and older)
- Consent for Services and Financial Policy
- Consent to Communicate (18 years and older)
- Demographic Form
- Mental Health Consent to Communicate (under 18 years old)
- Minor Consent for Services (13-17 years)
- MSHSL Student Athlete Post COVID-19 Return to Sport
- Sports Qualifying Physical Examination Clearance *Please complete all questions on page 2 along with a parent signature prior to sending in your form
Contact Us
Health Information Management
Phone: 952-401-8315
Fax: 952-401-8242
healthinformation@slpeds.com
South Lake Pediatrics
Attn: HIM Department
17705 Hutchins Dr #250
Minnetonka MN 55345
