Patient Forms & Express Check-in

Please follow the steps below and click on the links, highlighted in blue, to access the forms.

The following steps need to be completed 48 hours in advance of your appointment time.

Express Check-In Steps

1st STEP

  1. Print and read WELCOME letter.
  2. Print, complete and sign PATIENT PROFILE (2 pgs).
  3. Print HIPAA POLICYthis is for your records only. It is not necessary for you to bring it with you to our office or send back to our office.
  4. Print PATIENT MEDICATION LIST – Please list ALL known prescriptions, over the counter, herbal /vitamins/minerals and dietary supplements with dosage, frequency & route of administration, i.e. oral, topical.
  5. Print, initial, sign and date the GUARANTOR BILLING AGREEMENT. This is an agreement between the patient and Summit Skin and Vein Care.
  6. Copy of driver’s license
  7. Copy the front and back of your insurance card(s) – please verify that the “copy” of your insurance cards are legible before sending to our office.

2nd STEP

  1. Fax all of the above documents to (816) 554-9470
  2. Mail to us at: 3521 NE Ralph Powell Rd, Ste C, Lee’s Summit, MO  64064

3rd STEP

  2. Complete Demographics
  3. Complete Insurance Information
  4. Complete Medical History

Note: The information from the Patient Portal will be reviewed at the time of your appointment.

4th STEP

Arrive 15 minutes prior to appointment to:

  1. Check-in
  2. Sign any additional paperwork
  3. Make payment for copay, coinsurance and / or deductible


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