SHAWNEE COUNTY HEALTH DEPARTMENT - Family Planning Registration and Health History Form

Please complete at least 2 business days before each appointment.

By completing this now, you will save 15-20 minutes in the waiting room on the day of your appointment. If you close your browser window before completing, you will need to start at the beginning. Please use the tab button or your mouse to move to the next question; the enter button will skip to the next page.

Remember to bring your photo id, insurance card and proof of income to your appointment.

If you need to reschedule or cancel your appointment, please call 785-251-5700.

1. Name: *This question is required.

First Name
Middle Initial
Last Name

2. Preferred Name:

3. Date of Birth: (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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