Monday - Thurday - OPEN

Friday to Sunday - CLOSED

(913) 631-0277

mrichardsonmd@kcmedicalwc.com

5407 Johnson Drive

Mission, Kansas 66205

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CONTACT INFO

(913) 631-0277

mrichardsonmd@kcmedicalwc.com

5407 Johnson Drive

Mission, Kansas 66205

INTAKE FORM


















    Please list contact information for any physician(s) or facilities that have treated you for the condition that you are seeking treatment for (if applicable)…



    Physical History:


    Please list any prescription medications, OTCs (over the counter medications), vitamins, minerals, supplements you are taking. Please list the amounts (i.e. 500 mg tablet 2x/day), when you take them (schedule) and why you are taking them.*

    Physical History: Please check all if you have or had any of the systems.


    Headaches-one sidedConfusion, Brain FogBlurred VisionHeadaches-involves back of neckDizziness, UnsteadinessHeadaches-associated with light sensitivityHeadaches-interfere with workChange in memory


    Social History: Please circle all that apply.



    PMI/FH: Have you or any of your family members had any of the problems listed below?




    READ THOROUGHLY BEFORE SUBMITTING


    PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

    I hereby acknowledge receipt of the Notice of Privacy Practices for KC WELLNESS CENTER regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting KC WELLNESS CENTER, 1412 NW Vivion Road Kansas City, MO 64118.


    ACKNOWLEGEMENT OF FEES

    I hereby acknowledge receipt of notice that KC Wellness Center does NOT file health insurance claims at this time. I understand that I am personally responsible for payment in full for the care that I receive at the time of service. Once a service has been rendered the fees paid are non-refundable. KC Wellness Center will provide you with documentation to submit to your insurance carrier so that you may be reimbursed for your medical expenses directly. I further understand and agree that if KC Wellness Center must take any action to collect an outstanding balance on my account, I will be responsible for payment of and will reimburse this office for all costs of such collection efforts, including but not limited to staff expenses at a rate of $25 per hour, court costs, postage and attorney fees. I agree to the following fee schedule.

    Initial Consultation is Free
    New Patient evaluation fee $250
    Established Patient follow up visit fee $65
    Varies based on medical necessity


    ONLINE REVIEWS

    We very much appreciate honest reviews posted on social media and online search engine pages. By signing this agreement, you give your expressed permission to KC Wellness Center and or its officers and providers to respond appropriately to any review(s) you may post.


    OFFICE WAITING AREA POLICY

    KC Wellness Center, Inc. is a small medical office with very limited space for guests waiting. We have to ask our patients to limit the amount of guests with them to one guest. We apologize for the inconvenience and appreciate your understanding. Additionally there are no foods or drinks other than water permitted in the waiting area. By signing this, you are agreeing to honor these office policies.


    CONSENT TO TREAT

    I hereby authorize the Doctor’s to treat my case as they deem appropriate.