The following forms are available for you to download and print at your convenience:

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General

• Registration Form

• Initial History Questionnaire:

  • Newborn

  • Transfer

• Well Child/Adolescent Information Update for Chart

• HIPAA Privacy Notice

• HIPAA Acknowledgement of Receipt and Adherence to Office Policies

• Authorization to Exchange Protected Health Information

• Consent For Caretaker

• Consent For Care For Unaccompanied Child

• Alternative Method of Communication Consent

• Laboratory Preference Form

MyChart

• MyChart Child Proxy Form

• MyChart Adolescent Proxy Form

Vaccination Consent 

• COVID-19 Vaccination Consent Form

At each well visit, we will provide you with a completed state school physical examination form and immunization record. This form is good for one year, and you may photocopy it and submit it in response to medical information requests from school, camps, and sports organizations throughout the year.

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