Forms

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New patient paperwork includes:

Information Sheet – Please complete one per family, with all children and birth dates listed at the top. A parent or guardian signature is required at the bottom of page 2.

Medical History Sheet – Complete one form for each child.

Financial Policy – Information about our financial policies and insurance.

Missed Appointment Policy

Notice of Privacy Practices

Medical Record Transfers

Medical Release Form (From Pediatric Care, Inc.)

Medical Release Form (To Pediatric Care, Inc.)

Miscellaneous Forms

Vanderbilt Parent Initial Assessment

Vanderbilt Parent Follow Up Assessment

Vanderbilt Teacher Initial Assessment

Vanderbilt Teacher Follow Up Assessment

Controlled Substance Policy

Ohio Sports Form

Child Medical Statement for Daycare and Type A Homes

18 Year Old Authorization to Disclose Information

Developmental Forms

1 month/2 month/4 month Visit
Edinburgh Postnatal Depression Scale (EPDS)

5 Year Visit
Tuberculosis Screening

18 Year Visit
Authorization to Disclose Information to Parents or Guardian