New Patient Forms for Men and Women (Please complete all of them)
- Patient Registration/Assignment of Benefit
- Encounter Form
- Review of Symptoms Form
- Patient, Family History Form
- Patient Registration/Assignment of Benefit
Established Patient Forms
- Encounter Form -done at every visit -please complete entire form.
- Medicare Wellness Checkup -an important review done once every year.
Child Care Forms
To Use KIDS developmental charts – go to the bottom of the page and circle your child’s age and work up, “x”ing each box that they have the capacity to accomplish. When you hit the dark stair-stepped line, you have reached “normal” for that age – but you should keep going until the form is asking for things that your child has not yet done.
- 1-24 developmental screening- Please, complete before each "well child visit".
- 24-69 developmental screening - Please, complete before each "well child visit". Until age 6.
- Sudden Cardiac Event Screen - Please, complete for a "well child visit" upon entrance into middle school.
- Autism screening - Complete if any parental concern.
- Younger adolescent questionnaire - Please fill out before appointment
- Middle & older adolescent questionnaire- Please fill out before appointment
- Raising children parent questions 4-5 years - for your thoughtful consideration, bring with you if you have concerns or questions.
- Parental expectations of a child 4-5 years - for your thoughtful consideration, bring with you if you have concerns or questions.