Forms
New Patient Packet
Complete this form to provide new patient 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.
Complete this form to acknowledge receipt and understanding of our HIPAA Privacy Policies
Lactation Moms Registration
Complete this form to provide new patient demographic information, insurance, consent for us to treat you as a mom seeking consultation with our lactation specialist
Complete this form to acknowledge receipt and understanding of our HIPAA Privacy Policies
Established Patient Forms
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.
Complete this form to acknowledge receipt and understanding of our HIPAA Privacy Policies
Complete this form to confirm insurance and responsible party on the patient account, as well as update who is able to call for information, bring your child in for an appointment, consent to treatment, and / or pickup documents and prescriptions.
Release of Information Forms
Patient Authorization for Use and Disclosure of Protected Health Information Form [PDF] Complete this form if you are transferring your medical records
Choose option below to complete consent form for your child of driving age who wishes to attend their appointment alone
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
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
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.
