Family
Medical History:
This form should be completed by all new patients, or if a child's family history has changed, generally updated at the time of a child's regular physical exam.
Lead
Poisoning/TB Screening: This form should be fully completed for all children 6 mos-5 years, at the time of the child's checkup. For children 6 years and older, only the TB questions need to be completed.
Patient
Eligibility Screening Form: This form needs to be completed once, usually done at the time of a child's checkup. It is a form that the state has asked us to obtain and keep in the child's record.
Medication
Order: This form needs to be completed if your child is going to need to take prescription medication during school hours.
Participation
Physical Evaluation: This form should be completed by all children 13 years and older at the time of their physical exams. It is for the child to complete, often needing help from a parent.
Patient
Information: This form is completed by all new patients and updated any time demographic information has changed. Occasionally we ask you to update this form, simply because it has been so long since the last update.
Authorization
to Use or Disclose Protected Health Information:
This form should be completed by the patient who is 18 years or older, or by the parent for a child under 18 years. It should be completed if the patient is transferring to another physician, or anytime you would like us to release information to a third party.
Acknowledgement:
Notice of Privacy Practices: This form is completed to state you have seen our Privacy Practices Document.
A link to this Privacy Policy is also located at the bottom of our home page. This form only needs to be filled out once per household.
