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  • Providers
    • Charles F. Cockerell, MD
    • Michele C. McIntosh, MD
    • Mark A. Mozer, MD
    • Joseph R. VanBiber, DO
    • Annette M. Beck, MD
    • Cindy L. Kirby-Diaz, MD
    • B. Ashley Campbell, DO
    • Tyler J. Murtaugh, MD
    • Amanda DuMers, C.P.N.P.
    • Kathryn A. Ryan, C.P.N.P.
    • Amy MacCuish, C.P.N.P.
    • Natalie Elzinga, C.P.N.P.
    • Kayce Erikson, FNP
    • Jennifer Osgood, C.P.N.P.
    • Christina “Nicky” Spears, CPNP
  • Services
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    • Effective TECH Parenting
    • Car Seat Guidelines
    • Car Seat Guidelines Spanish

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Well Visit Packets

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Patient Forms

Please click on any link below to download an Adobe Reader® file of that form. Print, complete and bring the forms with you to your next appointment.

  • Patient Information Sheet
  • HIPAA Privacy Policy Acceptance Form
  • Notice of Privacy Practices
  • Financial Policy
  • Missed Appointment Policy
  • VFC (Vaccines for Children)
  • Medical Records Release Form
  • ADHD Progress Report
  • ADHD Progress Report - Spanish
  • ADHD Parent Assessment
  • ADHD Teacher Assessment
  • ADHD Parent Followup
  • ADHD Teacher Followup Teacher Followup
  • Allergy Questionnaire
  • Allergy Questionnaire Spanish
  • Allergy Symptom Calendar
  • Vaccine Policy Statement
  • Modified Checklist for Autism in Toddlers
  • Modified Checklist for Autism in Toddlers Spanish
  • Effective TECH Parenting



Cockerell & McIntosh Pediatrics

205 NW R.D. Mize Rd., Suite 304  •  Blue Springs, MO 64014
11200 Winner Road  •  Independence, MO 64052
1717 N. Main Street  •  Higginsville, MO 64037

Appointments: (816) 655-0102
Phone: (816) 228-4770
Fax: (816) 228-1156

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© 2021 Cockerell & McIntosh Pediatrics