Forms & Policies

view our policies

view our forms

These forms are provided to help us provide better service to you. Please download them, fill them out on your computer, and then print them to bring to your visit for faster service. We understand that you have busy schedules and are looking for quick yet quality service.

New Patient Forms

  • Medical History Form - english / spanish
  • HIPAA Form - To protect your privacy when disclosing information to us - english
  • VFK Form - Please complete if your child is covered by Kidcare, Allkids, or Medicaid in order for us to provide your child's vaccinations at our office - english
  • Authorization to Release Information - Transferring In - Please complete and send to your previous provider in order for us to obtain your child's records ahead of your visit. Please note we must have your child's vaccination records before their first visit - english
  • Authorization to Release Information - Transferring Out - Please complete so we can send your child's records to your new provider. english
  • Tuberculosis / Lead Risk Form - english / spanish
  • Consent for Non-guardian to Authorize treatment - If your child needs to be brought to a visit by a non-guardian, please fill out the form and send it with your child on his/her visit - english / spanish
  • Pediatric Symptom Checklistenglishspanish

Visit Specific Forms

0-12 Month 10 Month 15 Month 18 Month 24 Month Asthmatic Patients

Forms for Physicals

  • Daycare / School Physical - english
  • Sports Physical Form - english
  • School Consent to Self-Administer Asthma Form - english

ADHD Evaluation Forms