Weight Management New Patient Information Form Page 2
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Dear Provider,
Please complete this form, and FAX it to the lab or give it to your patient to take with them to the lab. Thank
you for your referral to the Weight Management Screening clinic. In order to fully evaluate your patient, the
following FASTING lab studies and GROWTH CHART/ BMI CHART are needed prior to the clinic visit. If your
patient’s insurance plan allows, the benefit level is acceptable and transportation is not a barrier, we would
prefer that the labs are obtained at a Children’s Mercy Hospital location. This will help minimize delays in
receiving lab results and facilitate access to lab results while we see the patient in clinic. Please call our clinic
coordinator at (816)234‐9244 with any questions about the recommended lab below. Please FAX the lab order
below to a CMH lab, or if the lab is obtained elsewhere, please FAX the results as soon as they are received to
(816) 960‐2855.
Patient Name__________________________________________ Patient date of birth__________________
*
*
M
u
s
t
b
e
F
A
S
T
I
N
G
1
2
h
o
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a
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*
*
*
*
M
u
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F
A
S
T
I
N
G
1
2
h
o
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r
s
p
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*
*
Diagnosis:
Obesity (278)
Polycystic Ovary Syndrome (256.4)
Other_______________
Insulin
BMP
Lipid Profile
Liver Function Tests
HbA1C
If your patient has signs of Polycystic Ovary Syndrome such as hirsuitism or amenorrhea, please also obtain:
17‐ OH Progesterone DHEAS Androstenedione L‐Wrist Bone Age
Provider Signature: ________________________ Date: ___/___/____
Provider Name (printed): ____________________________________
Provider phone: ________________________
The following CMH laboratory locations are available:
Children’s Mercy Downtown
Children’s Mercy South
th
2401 Gillham Rd, Kansas City, MO 64108
5808 W. 110
Street, Overland Park, KS 66211
Outpatient Lab: Monday‐Friday
Phone: (913) 696‐8210
Lab Hours: 7a.m.‐ 7p.m.
Fax: (913) 696‐8021
(Enter through Main Entrance)
Lab Hours:
Phone (816) 234‐1530 (Outpatient)
Monday‐Friday 8:30a.m.‐6p.m. Saturday 9a.m.‐1 p.m.
Fax: (816) 234‐1531
Children’s Mercy Downtown
Children’s Mercy North
2401 Gillham Rd, Kansas City, MO 64108
501 NW Barry Road
Main Lab: 24 hours a day, 7 days a week
Kansas City, MO 64144
(Enter through Emergency Room)
Phone: (816) 413‐2520
Phone (816) 234‐3230
Fax: (816) 413‐2530
Fax: (816) 234‐3794
Lab Hours: Monday 7:30a.m. ‐ 5p.m.
Tuesday‐Friday 8:30a.m.‐5 p.m.
Updated 5/2/11
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