Before Each Visit

To make your visit as productive as possible, you may print out some applicable forms and fill them out at home, and then bring them to your visit.

New Patient Forms

Receipt of HIPPA Privacy Practices and Research Information: Please print this out, sign it, and bring it to your first visit. It acknowledges that you have been given information about our privacy practices and your rights under HIPPA, and also informs you of the ways the practice participates in academic research, and your right to decline to be part of that. Please review our privacy practices and your rights under HIPPA by clicking here: HIPPA. Access to this link constitutes being given this information. If you would like a paper copy of this information, please request it.

Regarding research: The practice occasionally participates in research projects related to pediatric care. As part of this research, we may provide data about our patients to academic research teams.  These data are always anonymous, or “de-identified,” meaning that researchers are not able to link data to specific children. For example, we do not provide parent names, patient names, date of birth, date of office visit, street address, or any other pieces of information that could be used to identify a patient. Parents can decline to have their child’s data be part of this.

Consent for Care/Authorization for Others to Seek Care: This form is filled out at our office. It indicates that you consent to have your child treated at our facility, and allows you to designate (only if you wish) other adults who are allowed to bring your child to the doctor and to know their medical information.

New mother post-partum depression screen: Please complete this form for all newborn visits.

Here are forms that relate to well visits. They can be filled out even if there are no concerns, since they may bring up a concern.

Peds Screen: All 2 month olds to 8 year olds at well visits. This checks for developmental problems. This link costs $10, or can be done in office for free if you prefer.

Revised MCHAT: All 18 month olds, 2 year olds and 2 and a half year olds. This screens for autism.

Pediatric symptom checklist to screen for emotional issues: Please fill this out yearly at the well-visit.

Teen survey form: Patients age 13 and up should fill these out yearly. You can use this instead of the pediatric symptom checklist above.

Here are some extra forms that can be filled out if you have concerns relating to them.

ADHD screen: For parents to fill out about your child if you have concerns about Attention Deficit Disorder.

ADHD teacher screen: For teachers to fill out about your child if you have concerns about Attention Deficit Disorder.

Asthma control score: Fill this out at every asthma visit, or use it to check if you need an asthma visit soon!

Depression quiz for teens and young adults: Print out your score and bring it in.

Headache Diary: Fill out one for each headache you have, for at least 4-6 headaches, then come in.

Here’s a link to a baby sleep pattern chart that you can download and use to keep track of your child’s sleep patterns. Fill this out if you are coming in for a problem with your child’s sleep.