If this is your first time appointment or you are new patient for clinic, print and fill out all the forms below link. Please bring them with your appointment. Thank you
!
*
Patient Registration Form
*
Assignment of Benefits - Financial Responsibilities
*
Patient Financial Policy
*
Patient Health History Questionnaire
*
Patient Health History Questionnaire Instruction Sheet
*
Survey
*
Notice of Privacy Practies
Galichia Medical Group, P.A.
2600 N Woodlawn
·
Wichita, KS 67220
1.316.684.3838
·
1.800.657.7250
service@galichia.com
Copyright © 2001 by
All rights reserved.
Term & Conditions