Welcome to Bloomington Pediatrics

Forms

Patient Registration Forms

Patient Information Sheet

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.

Acknowledgement of Notice of Privacy Practices

Complete this form to acknowledge receipt and understanding of our HIPAA Privacy Policies

Release of Information Forms

Medical Records Release Form

Patient Authorization for Use and Disclosure of Protected Health Information Form [PDF] Complete this form if you are transferring your medical recor

Consent to Treat an Unaccompanied Minor

Click here read our office policy. Choose option below to complete consent form for your child of driving age who wishes to attend their appointme

Under 18 Release of Information

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 in

Age 18-20 Release of 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 inf

Age 21 and Over Release of 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.

Patient Screening Tools

Adolescent Depression Screening

Heart Health Questionnaire for Young Athletes

Edinburgh Postnatal DepressionScale

Vanderbilt ADHD Parent Questionnaire

Vanderbilt ADHD Teacher Questionnaire

Vanderbilt ADHD Parent Questionnaire - (Spanish)

Vanderbilt ADHD Teacher Questionnaire - (Spanish)