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Call Us Today! 
Call Us Today! 

Established Patient Paperwork

Please fill out the following forms yearly and email back to our office at prior to your appointment. 

In order to email the completed forms to our office, please save them to your computer and then attach in an email to our office. You will sign the forms in the office at the time of your appointment. You can also print the completed forms at home and bring them with you to your appointment. 

Note: If you decide to fill out these forms and then email them back to us, please be aware that you have a choice to either send documents via email (which is not protected) or you can print, complete and return the forms on site to our practice. 

Please be sure to bring your insurance card and your driver’s license or other photo I.D. with you to your appointment. 
Please visit the FAQ section of our website for important insurance information about your first appointment. 

Please fill in the following forms: 

Patient Demographic Info and Financial Release  

Compound Authorization Form/Release of Information 

HIPAA Notice of Privacy Practices

If you are being seen in our office for your pregnancy, please read and complete the following forms in addition to those listed above. 

Obstetrical Policy, Ultrasound Form, HIV Testing Consent Form

Birth Defects Risk Assessment

Contact Information

Northland Women's Health Care, PC

5844 NW Barry Road, Suuite 310
Kansas City, Missouri 64154

Phone: 816-741-9122
Fax: 816-741-9665

Payment Options


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