Forms & Documents

Child Registration for children younger than 18: Demographic form for new patients younger than 18 years of age

Child Registration for children older than 18: Demographic form for new patients greater than 18 years of age

Health information: New patients need to fill this out, along with one of the registration forms above.

Non-Parental Caretaker Registration: This is for children who will be brought to the office by someone other than a parent or legal guardian, giving us permission to see the child with another adult.

Parent registration: Parents wishing to get vaccines at our office need to complete this

Change of address

HIPAA privacy practices Our practice’s policies to protect your privacy includes how we use your private information and your health information rights.

Privacy acknowledgement We will ask all families to review our privacy policies to ensure that you understand them and have had a chance to ask any questions about privacy issues. All families must sign this form.

Medication Feedback Sheet: This is filled out by parents or the child at every medication recheck visit (such as for ADD, anxiety, or depression).

Records Request from another office: For new patients, or for patients who have been seen at another facility.

Flu vaccine screening form: Helps parents decide which flu vaccine is appropriate for a child

Tylenol and Motrin Dosing

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