Patient Forms

We realize how valuable your time is, so in an effort to expedite your in-office visit, we’ve made some of our most requested forms available for download. At your convenience, the forms below can be printed, filled out, and brought with you to your next visit.

Act 52 Medical Consent Authorization (PDF)
Completed by a parent/guardian of a minor to authorize another person to seek medical treatment for their child, i.e., grandparent, aunt, etc.

Designated Representative for Medical Consent (PDF)
Completed by patients over 18-years-old to appoint a personal representative to act on their behalf, i.e. parent, grandparent, etc.

Family Advisory Committee Application (PDF)
Completed by family members who are interested in participating in the Center of Excellence for Childhood Substance Use’s Family Advisory Committee.

New Patient Request Form (PDF)
Completed by a parent/guardian to register a new patient with a Children's Community Pediatrics practice.

Request of Release of PHI (Medical Records) to or from Children’s Community Pediatrics and Children’s Express Care (PDF)
Completed by parent/guardian ,or patients over 18-years-old, to request medical record release from Children's Community Pediatrics or Children's Express Care to another physician/practice.

Informational Statements

Notice of Privacy Practices and Summary (PDF)
Describes how medical information may be used and disclosed and how you get access to your medical information.

Vaccine Information Statements
Vaccine Information Statements (VISs) are information sheets produced by the Centers for Disease Control and Prevention (CDC) that explain to vaccine recipients, their parents, or legal representatives both the benefits and risks of a vaccine.

ADHD Assessment Forms

NICHQ Vanderbilt Assessment Scale (Parent Initial) (PDF)
ADHD initial assessment to be completed by parent and returned to pediatrician.

NICHQ Vanderbilt Assessment Scale (Parent Follow-up) (PDF)
ADHD follow-up assessment to be completed by parent and returned to pediatrician.

NICHQ Vanderbilt Assessment Scale (Teacher Initial) (PDF)
ADHD initial assessment to be completed by your child’s teacher and returned to pediatrician.

NICHQ Vanderbilt Assessment Scale (Teacher Follow-up) (PDF)
ADHD follow-up assessment to be completed by your child’s teacher and returned to pediatrician.

Mental Health Screening Tools

Generalized Anxiety Disorder 7 (GAD-7) (PDF)
Completed by patients 18-years-old and older.

Patient Health Questionnaire 9 (PHQ-9) (PDF)
A questionnaire completed by patients, ages 12 to 18, that screens for depressive disorders.

Pediatric Symptom Checklist – parent completed version (PSC) (PDF)
The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. This form is to be completed by parents/guardians.

Pediatric Symptom Checklist – youth completed version (Y-PSC) (PDF)
The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. This youth self-report form is for patients 11 to 18 years old.

Screen for Child Anxiety Related Disorders (SCARED) Parent Version (PDF)
This questionnaire can be used to identify patients who require further evaluation or treatment for anxiety disorders. This form should be completed by the patient’s parent/guardian.

Screen for Child Anxiety Related Disorders (SCARED) Child Version (PDF)
This questionnaire can be used to identify patients who require further evaluation or treatment for anxiety disorders. This form should be completed by the pediatric patients ages 8 to 18.