Forms & Policies

Patient Forms

Here is a list of our forms. You can save time during your visit by reviewing this list and bringing in the form already filled out. If you are bringing your child in for an annual well visit, for example, please review our Well Visit Assessment forms, download the form corresponding to your child’s age, print it, fill it out and bring it with you to your visit.

Download Patient Forms

Below are general forms available to download.

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General Forms

    Well Visit Assessment Forms
    Save time during your child’s well visit by downloading the form that corresponds with your child’s age/ well visit, fill it out and bring it with you to your visit.
    Form Well Visit
    Anemia / Lead Risk Assessment Anemia: 4 months, 18 months, annually at well visits between 3 - 18 years

    Lead: 6 months, 9 months, 18 months, and all well visits from 3 – 6 years
    TB (Tuberculosis) / Cholesterol Risk Assessment TB: 1 month, 6 months, 12 months, 18 months, annually at well visits between 2 years -18 years

    Cholesterol: 2 years, 4 years, 6 years, 8 years and annually at well visits  between 10 -18 years
       

    Medical Release Form- FORM B

    Request to Restrict Health Information- FORM A
    Download this form, fill it out and fax to your office if you are:
    • Requesting a copy of your child’s medical records released/sent to another physician’s office.
    • Requesting a copy of your child’s medical records for your own files (charges apply – see Form B).
    • Requesting that a portion of your child’s protected health information be disclosed to another party.
      		Download this form if you are a patient requesting restriction of a visit or test/lab result or any particular item contained in your record.

      Download this form if you are a parent who wants to restrict your child’s records from being seen by anybody other than the legal guardian. Court documents may be required.

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