Patient Forms

Patient Registration Forms

These registration forms will need to be completed for all new patients and renewed annually thereafter.

  • Patient Information Sheet [PDF] [Secured Online Form]
    • Complete this form to update demographic information, insurance, consent for us to treat your child and consent for another adult (other than parent or legal guardian) to accompany your child to their appointment. 
  • HIPAA Form - Notice of Privacy Practices [PDF]

Release of Information Forms

The privacy of patient information is very important to us. Please help us keep your child's patient record safe by completing one of the consent for release of patient information forms below which is most appropriate for your specific need.

  • Medical Records Release Form - Patient Authorization for Use and Disclosure of Protected Health Information Form [PDF] [Secured Online Form]
    • Complete this form if you are transferring your medical records. If you choose to print the PDF, please mail it or drop it off at our office. We will make every effort to copy and send out your records within 10 business days, usually at no charge.
  • Treatment of a Child in the Absence of a Parent or Legal Guardian - follow link to read our office policy. Choose option below to complete consent form for your child of driving age who wishes to attend their appointment alone.
  • Choose an option below to consent for someone other than the patient or legal guardian to have access to patient information. This access includes the ability to receive information in over the phone and pick up documents in the office.
    • Under 18 Release of Information [PDF] [Secured Online Form] - choose this option for the parent or legal guardian to consent to another family member or adult to have access to your under age 18 child's patient information. This consent expires when the patient turns 18 years old and a new age release must be signed by the patient.
    • Age 18-20 Release of Information [PDF] [Secured Online Form] - patients between the ages of 18 and 20 must complete this release to allow a parent, legal guardian or other adult to have access to their patient information. This consent expires when the patient turns 21 years old and a new age release must be signed.
    • Age 21 and Over Release of Information [PDF] [Secured Online Form] - patients age 21 and older must complete this release to allow a parent, legal guardian or other adult to have access to their patient information.

Patient Screening Tools

Contact Us

Non-Medical Inquiries Only. If you have an ill child, please contact the office directly by phone.

Location & Hours

Our Location

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Hours of Operation

Our Regular Schedule

Our Pediatric Office

Monday:

8:00 am-5:00 pm

Tuesday:

8:00 am-5:00 pm

Wednesday:

8:00 am-5:00 pm

Thursday:

8:00 am-5:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

08:00 am - 12:00 pm - Only same-day, urgent, sick visits by appointment.*

Sunday:

Closed