Online Forms by Success Health System LLC

For each form, please click or copy and paste the related URL to your browser, then fill out the form. Contact us for more information or schedule an appointment online. We have convenient locations to serve you in Creve Coeur MO, Independence MO, and Columbia MO.

Enquiry Submission form (Contact Form):

New Patient Registration Form:

Review the forms carefully and adhere to the following Instructions for Completion:

• Mandatory Name, Signature and Date on page 13.
• Mandatory Photo on Page 14.
• Mandatory Signature on Page 15.
• Mandatory Signature and Date on Page 16.
• Name Signature and Date on Page 17 and 18.
• Mandatory Name, signature and Date on Page 20.
• Complete Page 21, ONLY IF YOU ARE SELF PAY.
• Mandatory Name, Signature and Date on Page 21.
• Complete Pages 22 and 23 ONLY if needing SUBOXONE
• Mandatory Name, Signature and Date on Page 24.
• Complete Pages 25-27 if you are an Adult patient, age 18 and older.
• Complete Pages 28-30 if you are a Child/Adolescent patient, Younger than age 18.
• BE SURE TO FILL OUT EACH FORM COMPLETELY. Click DONE/FINISH to submit.

Success Health System Release-Obtain Medical Records:

Provider Referral Form:

Consent to Treatment Form:

Success Health System Medical Records Request Service Fee Agreement:

Acknowledgement of Privacy Form:

Direct Care Patient Agreement Form:

Insurance Contract Form:

Intake Form ADULT:

Intake Form CHILD/ADOLESCENT:

Follow UP Form (All Ages):

Suboxone Treatment Contract Form:

Self-Pay Contract Form:

Medication Refill Request Form:

Success Confidentiality and non-disclosure agreement: