Registration Forms

If you have email, please sign into the portal to sign your consent forms.
To get to the portal, select the 'Patient Login' box in the upper right corner of this page.
You can set up a portal account from there, or sign into an existing account.

If this is your first time logging into the new portal, since 01/01/2017, please sign the consent forms. There are three forms to sign. (Consent to Treat; Notice of Privacy; Medication History Download)
Here's how to get the the three consent forms:
     Select MY HEALTH
     Select MEDICAL FORMS"

 

There are 2 ways to sign:
Sign electronically: Simply open the form, read it, check the acknowledgement box, type your name into the name box, & click 'submit'. (If you are not the patient, you will need to fill in the relationship box and enter a reason... eg; child.)

Print forms and sign. Bring them with you to the appointment.

Next, print:
Healt Questionnaire if you have not been seen since 1/1/2017. Complete the form, sign it and bring it with you. 
Registration Form if you are a new patient. Complete the form, sign it and bring it with you. We will verbally confirm all information on this form if you are a return patient.

If you don't have an email account, you can print the forms from here. (see below)
Complete, sign and bring them with you.

Print Forms Here:

Financial & Billing Policy/Consent Form Financial Form
Notice of Privacy Practices Privacy Form
Medication History Downloads History Form
Patient Registration Form Registration Form
Health Questionnaire Form Health Form

 

We will check your cards at each visit, so please be prepared to present your cards at check-in.


 


         

Copyright © 2017 Laura Wagner, MD. All Rights Reserved.
14377 Woodlake Dr. #111 • Chesterfield, MO 63017
314-434-1111