For Patients

Patient Forms

Printing new patient forms and filling them out prior to your visit with a provider can be very helpful and save you time in the long run.  Listed below are a couple of the new patient forms that have been provided to us by our visiting specialists.  There is also a general new patient form that can be used for a visit at the Chase County Clinic to ensure your health history records are up-to-date.


FLU SHOT CONSENT --Vaccination information sheet is first followed by consent on page 3

Chase County Clinic New Patient Form or to update records

Dr. Fitzpatrick Adult New Patient Form

Dr. Fitzpatrick Child New Patient Form

Dr. Heirigs New Patient Form

Dr. Mosel New Patient Form

Dr. Mosel Adult History Form

Dr. Mosel Pediatric History Form

Dr. Mosel Payment Policy Form page 1

Dr. Mosel Payment Policy page 2