Patient Forms

In preparation of your appointment, you may be asked to complete some or all of the forms listed within the Pediatric or Adult sections below.

Note: All the forms below are posted in PDF file format. You will need the free Adobe Acrobat Reader software to view and print out these forms. The Reader software is available here.

These files could take some time to download, so please be patient.

Pediatric Patients

• Pediatric Patient History (PDF)
• Consent and Authorization for Release of Information (PDF)
• Patient Information Sheet (PDF)
• Pediatric Patient Data (PDF)
• Parent Questionnaire (PDF)
• New Patient Referral (PDF)
• Request for Release of Medical Records (PDF)
• Court Appointed Guardian (PDF)
• Patient Request For Release Of Medical Records

Adult Patients

• Adult Patient History (PDF)
• Consent and Authorization for Release of Information (PDF)
• Patient Information Sheet (PDF)
• Adult Patient Data (PDF)
• New Patient Referral (PDF)
• Request for Release of Medical Records (PDF)
• Court Appointed Guardian (PDF)
• Patient Request For Release Of Medical Records

Neuropsychology / Psychology

• New Patient Referral
  

To obtain more information about testing or neuropsychological evaluations, click on either of the following links - you will be redirected to a different website.

• Pediatric Neuropsychology Brochure
• Clinical Neuropsychology Brochure

Minnesota Epilepsy Group has also provided you with information on our privacy practices and collection policies for your review.

• Billing & Collection Policy (PDF)
• Notice of Privacy Practices (PDF)

Find a map and directions on the Contact us page.