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INFORMATION & FORMS

Various required forms are available on this page. Our office staff and/or providers may direct you to this page to print out and complete forms prior to your visit.

All the forms are in PDF format and require Adobe's Acrobat Reader which is free. If you do not have Acrobat Reader you can download it here.

YOUR CHILD'S WELL VISITS (ANNUAL CHECKUP)

Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop their optimal physical, mental and social health. You'll see how your child has grown in the time since their last visit, and talk with the provider about your child's development; For this reason, we do ask that only a parent or primary guardian accompany a child to their annual well visits.

 

Click the links below for more information: 

WELL VISIT FORMS

You can fill these out and bring them to your child's Well Visit to save some time!

NEW PATIENT FORMS

We aim to provide care in a comfortable and fun environment! We have provided forms below to make your first visit stress-free, concise, and enjoyable. If you are unable to complete the forms prior to your first appointment, we have them available at the front desk as well.

Please plan to arrive 15 minutes early for your first appointment in order to process the paperwork, and be sure to bring your insurance card.

If your child has been under the care of another pediatrician, we ask that you have the medical records transferred to our office including:

Most recent Well Check visit, growth charts, immunization records, lead testing results.

Any additional Well Check/Sick visit notes, specialist notes, and lab results that may be pertinent to your child's health are also encouraged. Please complete a Release of Medical Records form so that we can assist in requesting records on your behalf.

New Patient Packet - This PDF contains a compilation of all the forms you need for your new patient visit. Please complete each page and bring the completed packet to your first appointment. You may also download the individual documents below.

Release of Medical Records

Consent for Treatment of a Minor

Financial Policy

Vaccination Policy

New Patient History

Parent/Guardian Contact Info

Release for Assignment of Benefits

Notice of Privacy Practices
Privacy Practices Receipt

ADHD PARENT/TEACHER RATING

SNAP IV

ANXIETY SCREEN

Child/Teen Pages

Parent Pages

DEPRESSION SCREEN

Child/Teen Pages

Parent Pages

SCHOOL, CAMP, DAYCARE & SPORTS FORMS 

There is a $10 fee per set for completion of all health forms, due at drop off. Be sure all parent pages are present and completed, and that the child's name and DOB are filled out on every page. Please allow 3-5 business days for completion. We will call you once the forms are ready for pick up!

 

HARFORD COUNTY PUBLIC SCHOOL FORMS

Health Inventory - School/Daycare

Pre-participation Physical Evaluation - Sports Forms

Discretionary Medication Permission

Medication Policy Permission Form

Medication Self-Carry Permission Form

Immunization Certificate Form

Immunization Requirements

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