Forms and Checklists

This page contains links to all the standard forms used by our practice. If you download, print, and complete the appropriate forms before arriving, it will greatly reduce your time for the appointment.

Click Here if you're looking for our online forms for Prescription Refills, Referrals, Appointments, and Questions.

Please note: To use these forms you must have Adobe Acrobat Reader installed. If you have a newer computer, Acrobat is most likely already installed. If not, this free utility may be downloaded and installed through the Adobe Systems website at http://www.adobe.com/products/acrobat/. Click on 'Downloads,' choose 'Free Acrobat Reader,' and follow the instructions.

Description	Link to Form
Office Policies: This form is a printable version of our office policies. They may also be accessed online by clicking here.	[ Click Here for the Form ]
Assignment of Medical Care: This form is to be used when another person other than a parent or legal guardian will be bringing your child to our office for a scheduled appointment.	[ Click Here for the Form ]
Patient Information & Benefits Record Release: This is the main patient information and insurance data sheet. It needs to be updated yearly and when your address, telephone, or insurance information changes.	[ Click Here for the Form ]
Assessment of Lead Exposure: This is a simple questionnaire we use to assess your child's risk to lead exposure. It is usually completed prior to the nine month, 18 month, age 2, 3, 4, & 5 year checkup. It is also a mandatory test in certain Zip codes within the State of Maryland.	[ Click Here for the Form ]
Parent Delegation Form: This form authorizes us to give immunizations or medical care to a minor in the absence of a parent or legal quardian, but in the presence of your designated adult.	[ Click Here for the Form ]
Records Release Authorization: This form authorizes another medical institution or doctor's office to forward your child's medical records to our practice.	[ Click Here for the Form ]
Tuberculosis Risk Assessment: This is another simple questionnaire assessing your child's risk of tuberculosis exposure. It is usually completed prior to the 12 month and five year visit.	[ Click Here for the Form ]
Teacher Questionnaire: These are standard teacher behavioral checklists used by the school system to assess your child's behavior while in the classroom.	[ Click Here for the Form ]
Parent's Questionnaire: These are standard parent checklists which help us understand your perception of your child's behavior.	[ Click Here for the Form ]
Medical/Family History Questionnaire: This form is a detailed list of all medical problems in your family and your child's past medical history. It is confidential and is filed in your child's chart.	[ Click Here for the Form ]
Immunizations and Visit Schedule: This is the standard immunization schedule followed by our office.	[ Click Here for the Form ]
Parental Information: This form should be completed prior to your prenatal interview. It includes all vital information regarding your pregnancy and informs us of any expected health problems.	[ Click Here for the Form ]
Car Seat Standards: This is an informational fact sheet regarding car seat safety issues.	[ Click Here for the Form ]
Notice of Privacy Practices: As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.	[ Click Here for the Form ]
CDC Growth Charts: The two documents to the right contain CDC statistical data on growth v height v weight and other information. In addition, you may visit the CDC website for more information.	[ Click Here for Girls ] [ Click Here for Boys ] [ Click here for the CDC Web Site ] [ Click here for our Q&A page ]
Vaccination Consent Form For FluMist, Influenza Virus Vaccine, Intranasal: FluMist should only be administered to children and adolescents 5-17 years old and adults 18-49 years old who are healthy. Certain people must not receive FluMist. You must answer each question on this form, and have the answers reviewed by the health care professional to ensure you are eligible to receive FluMist. The health care professional will keep the questionnaire, and any information collected in a confidential manner.	[ Click Here for the Form ]
Heart Disease Risk Assessment Used to pre-evaluate your child's risk of a cardiac event.	[ Click Here for the Form ]

[ Go to top of page ]