Forms

Patient Forms

The first 1-8 forms are needed for new patient registration. Please complete them prior to your appointment,and bring them in to the first appointment along with your child’s Insurance Card and a Picture ID for the parent bringing the child in. Thank you!

New Patient Registration

  1. Privacy Policy (Download PDF)
  2. Privacy Policy Acknowledgement (Download PDF)
  3. Emergency Consent (Download PDF)
  4. Patient Information (Download PDF)
  5. Financial Policy (Download PDF)
  6. Electronic Prescriptions (Download PDF)
  7. Statement of Policies (Download PDF)
  8. Benefits Authorization (Download PDF)
  9. Authorization for Release of Protected Health Information (Download PDF)
  10. Notice of Acceptance of Text Messages (Download PDF)

Other Forms

ATTENTION PARENTS/GUARDIANS:

Our office charges for the following forms, requested after your visit to our office for your child’s well visit.

  • FMLA – $20
  • Shot Records – $5
  • Physical Form – $5 (Yellow & Sports)
  • Camp Forms – $10
  • Medical Records – $1.00 for the first 15 pages, $0.25 for each page after 15

Shot Record and Yellow Physical Forms will be given automatically at no charge on the day of your child’s well visit, along with any camp/physical forms that you bring to us. These charges will only apply when you need forms before your child is due for a well visit again. Our goal is to trim down the turn-around time for these requests, as our back to school season approaches.

Do we accept your insurance plan? Check this list to find out.