Pediatrics Forms

Patient Registration Forms
Please print and complete documents 1-6. Additional paperwork may need to be completed at the office.
  1. Pediatrics Health History Questionnaire
  2. Designation of Healthcare Surrogate for Minors
  3. New Patient Registration
  4. Consent for Treatment
  5. HIPAA Disclosure Authorization
  6. Authorization to Release Medical Records or Authorization to Release Medical Records (Español)
Additional Forms

ADHD Screening Forms

  1. Parent – Initial Vanderbilt Assessment
  2. Parent – Follow-up Vanderbilt Assessment
  3. Teacher – Initial Vanderbilt Assessment
  4. Teacher – Follow-up Vanderbilt Assessment
  5. Adult ADHD Self-Report Scale