Patient Forms

Download Forms

• Patient Information Form: While basic demographic can be entered and updated on the Patient Portal, the Patient Information Form must be completed
  • Patient Information Form
  
  
• Consent Forms: These forms must be signed once prior to the examination. This can be done in advance on the Patient Portal or at the initial visit check-in.
  • Notice of Privacy Practices - for your files
  • Receipt of Notice of Privacy Practices
  • Financial Policy
  • Consent for Use of E-mail
  
  
• Family History Form: Download and complete this form. Alternatively, it can be completed on the Patient Portal, under Questionnaires, Medical History.
  • Family History Form
  
  
• Medical Record Request Form: Please download, sign and send to the previous pediatrician. Please allow enough time for the records to received and processed by our office.
  • Medical Record Request Form
  
  
• Medical Record Release Form: Please download, sign and give to receptionist to allow Pediatric & Adolescent Medicine, LLP to send your child's medical records to another office. There is a copying fee for this service.
• Medical Record Release Form


• M-CHAT: The M-CHAT is administered as part of the 18-month old and 24-month Well Child Visits to help screen for developmental problems.
• M-CHAT


• Vanderbilt Forms: If requested by your Provider as part of ADHD management.
• Vanderbilt Assessment Scale - Parent Informant
• Vanderbilt Assessment Scale - Parent Follow-up
• Vanderbilt Assessment Scale - Teacher Informant
• Vanderbilt Assessment Scale - Teacher Follow-up