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. Call us for more information or schedule an appointment online. We have convenient locations to serve you in Creve Coeur MO, St. Louis MO, Independence MO, Columbia MO, and Olathe KS.

Enquiry Submission form (Contact Form):

New Patient Registration Form: 

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: