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About Us Patient Forms Our Facility Newborn Information Pediatric Advisor Patient Portal

About us

Patient Information

Patient Forms
Insurance Information

Our Facility

Newborn Information

Pediatric Advisor

Well Child Care


bottom strip Patient Forms

By printing these forms and completing them prior to arrival (you may either bring them to your appointment or fax it ahead of time), this makes your check in process much easier and overall visit time will be faster.

New Patients will need all of the following forms:

» Patient Information Form Under 18 Years old OR Patient Information Form Over 18 Years old

» New Patient Medical History Form Under 6 months old OR New Patient Medical History Form Over 6 months old

» Consent for the Use and Disclosure of Health Info (by signing this form, you are also stating that you have read the following HIPAA Patient Notice of Privacy Practices information sheet)

» HIPAA Patient Notice of Privacy Practices

If you need records transferred to or from another provider, you will need this form:
» Medical Records Release Form (if you are transferring care of your child from another facility to ours, please fill out this form and send/fax it to the other facility so they may send your records to us)

Forms for Established Patients

» Consent form to treat a patient in our office when accompanied by someone other than legal guardian

Medication Refills

We prefer that you use the following options in order:

- For controlled medications that have to be printed and picked up in the office, we prefer that you use our Patient Portal for medication refills

- For non-controlled medications, contact the pharmacy where you previously filled your child’s prescription and request a refill. They will send us a fax or electronic request and if there are no problems with the request we will return it to them in a timely manner.

- If you are using a different pharmacy, you may use the Patient Portal to request a different pharmacy.

- Lastly, if you are unable to use the first 2 options you may call our office and chose the option to request a medication refill and we will notify the pharmacy (this is the slowest and least efficient of the options, so please be patient as we process this request).

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