Patient Forms

To save time at your child's visit, please download these forms and fill them out at home, then bring them with you to the office.

New Patient Forms:

Medical Records Requests:

Notice of Privacy Practices:

For our patient's protection, if anyone other than a biological parent is accompanying the patient to the visit additional information will be required. If the information is not provided, the visit will be rescheduled.

  • Adopting/Foster Parents - If an adoption is still in process, court appointed paperwork must be provided proving that the person coming to the appointment is the adopting parent(s) and has medical decision making rights on elective procedures. If the patient is in foster care, including kinship care, and needs a procedure, consent forms and new patient forms must be completed and signed by DSS. We need a letter on DSS letterhead stating who can accompany the child to the procedure.
  • Non-Parent Family Members - If the patient is being seen for an office procedure or to discuss surgery a parent or legal guardian MUST be present. Legal guardians must have legal papers proving they have custody and medical decision making rights. Medicaid cards are not proof of legal guardianship. If the patient is coming in for anything else, we will need a photo ID of the person accompanying the patient and a letter signed from a parent stating who is authorized to bring the child. The person accompanying the patient must be an adult.

We are sorry for any inconvenience. Please call our office with any questions.