Info Request

HotButton InfoRequest

You may complete our Patient Forms online and submit them securely to our office, or just print a copy of the completed forms (and not click the Submit button – and make sure you print before leaving your browser window, as your entries will not be saved.) and bring them to your next appointment.

New Patients

Please fill out the following online forms prior to your appointment.

ButtonPatient Info Form

ButtonPatient History Form


Established Patients

Please fill out the following online form yearly. 

ButtonPatient Info Form

Please fill out the following online form if you haven’t been to our office for over three years. 

ButtonPatient History Form


Pregnant Patients

If you are being seen in our office for your pregnancy, please complete the following forms in addition to either the New Patient or Established Patent Package.

ButtonPregnant Patient Package

ButtonBirth Defects Risk Assessment

Northland Women's Health Care, P.C.
5844 NW Barry Road, Suite 310  •  Kansas City, MO 64154  •  Phone: 816-741-9122  •  Fax: 816-741-9665