Patient Forms

Please download, print and complete the forms below and bring them to your scheduled gynecology or bio-identical hormone replacement therapy appointment.  If you wish to complete paperwork at our office, please arrive at least 20 minutes prior to your appointment time.

Required forms

  1. Patient Information
  2. Female Patient History & Symptoms OR  Male Patient History & Symptoms
  3. Notice of Privacy Practices
  4. Authorization for Disclosure

Optional forms

The following forms are optional.

Risk Assessment for Lynch and HBOC Syndrome If you have a family history of cancer and would like to find out if you have an inherited risk, complete this form. We will discuss this with you in more detail during your appointment.

Records Request If you would like a copy of your records sent to another physician, please print and complete this form. Please note, there is a fee associated with sending medical records to another provider. The following fees will be charged, in accordance with the Kansas Department of Labor:

  • Up to 10 pages: $16.00
  • Up to 50 pages: $28.00
  • Over 50 pages: $28.00 + $0.35 for each page over 50

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Please be advised that we cannot provide a well exam and problem visit at the same time; separate appointments must be made. Please let our receptionist know if you need to make an additional appointment. 

Mirabile M.D. Beauty, Health & Wellness
4550 W 109th St., Ste 130 (I-435 & Roe)
Overland Park, KS 66211
After Hour Emergency: 913.894.3798