Please Note: Fields in red are required.
Salina Regional Health Center Authorization to Verbally Release Protected Health Information & Emergency Contact list
Personal Medical History (check all that apply)
Prescription and Non-Prescription Medication List
Thank you for choosing Salina Pediatric Care as the source of your child's healthcare. To help us get to know your child,
please take a few minutes to answer the following questions.
Is there a family history of any of the following? (please list child's parents, grandparents, siblings, aunts, uncles and cousins):
Please review your entries for accuracy before submitting the form.