Patient Forms

To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.

• Instant Medical History
• HIPAA - English
• HIPAA - Spanish
• Office Policy - English
• Office Policy - Spanish
• New Patients Form
• Welcome Letter and Checklist
• Initial History Questionnaire
• Medication Record Form
• Vaccine Policy Statement - English
• Vaccine Policy Statement - Spanish

In order to view or print these forms, you will need Adobe Acrobat Reader installed. Click here to download it.

What to expect

A pleasant, comfortable first visit builds trust and helps put the child at ease during future visits. We want your child to enjoy getting to know our doctors and staff, so we work hard to establish this bond during every appointment to our office. During your initial appointment, we will explain everything in detail and answer any questions you may have.

We look forward to meeting you and your child and providing the quality, comprehensive medical care you expect and deserve.

• Recommendations for Preventive Pediatric Health Care
• Early Steps Southernmost Coast Referral Passport
• Preparticipation Physical Evaluation
  

• Oral Health Risk Assessment Tool
• Milestones Form
• Fluoride Varnish and Oral Health Screening
• My Headache Diary
• Vaccines Contraindications Questionnaire Form
• Vaccines Contraindication Form
• NICHQ Vanderbilt Assessment Follow-up—TEACHER Informant
• WIC Medical Documentation for Formula and Food Form
• WIC Program Medical Referral Form
• The CHAT
• M-CHAT Tool
• CUESTIONARIO DEL DESARROLLO COMUNICATIVO Y SOCIAL EN LA INFANCIA (M-CHAT)
• Cuestionario M‐CHAT Revisado de Detección del Autismo en Niños Pequeños con Entrevista de Seguimiento (M‐CHAT‐R/F)™