Patient Forms

Patient and Office Forms

Preparing for your visit:

If you are a new patient to our facility, please be prepared to provide the following information:

  • Name
  • Address & Phone Number
  • Date of Birth
  • Social Security Number
  • Insurance Card

Patient Portal Information:

Patient Portal Enrollment Guide
Patient Portal User Name and Password Reset Instructions

Summit Healthcare:

Primary Care New Patient Packet
Notice of Privacy Practices

Pinnacle Sport Medicine and Orthopaedics:

New Patient Packet
Notice of Privacy Practices
Release of Information

The Woman’s Place:

Patient History Form
Release of Information
Laser Hair Removal Consent and Information
Notice of Privacy Practice
Sonogram Instruction Sheet
Gynecology Exam Consent Form for Minors

Summit Surgical:

New Surgical Patient
Notice of Privacy Practices
Release of Information
Anesthesia Evaluation Sheet
Colonoscopy Patient History
Surgery Instruction Sheet
Hibiclens Preparation
Colonoscopy Preparation Instructions

Pinnacle Rehabilitation & Sport Performance:

New Rehabiltation Patient Forms
Notice of Privacy Practice
Release of Information
KSHSAA Sports Physical Form

Mirage Imaging:

Notice of Privacy Practice
MRI Screening Form
Notice of Ownership


The Summit contracts with many insurance companies. We are required to collect your designated co-pay at the time of service. Please be prepared to pay your co-pay at each visit. Without it, you may be required to reschedule. If you have questions about your coverage, please contact our office prior to your appointment.

Self-pay patients and patients without proof of insurance are required to pay $200.00 in cash, check, or credit card at the time of service. In instances where the visit charge is higher, you will be billed for the difference. Failure to bring your expected payment may result in the rescheduling of your appointment.

Contact Customer Service —


HUTCHINSON | 620-662-6000
1818 E. 23RD AVENUE,