FORMS

Forms

Patient Demographic Form
This form is for updating any personal information including address, contact phone numbers, insurance information, and emergency contact information. If any of this has changed, please fill out this form.

Medical and Family History Form
This form is for giving your child's medical history and any relevant family medical history. If you are a new patient or if any family history information has changed, please fill out this form.

Faxing of Information Release Form
This form authorizes Pediatrics East to fax medical information such as excuses, medication lists, and sports physical forms to any person or party (such as your child's school or your job) that you want information sent. No medical information will be directly sent to anyone other than a parent or guardian without this form completed. Please note that this is NOT a transfer of records form. If you are wanting to transfer your child's medical records from another doctor's office to our practice, please use the forms below.

Transfer of Medical Records

If you are requesting your records to be transferred out, please download the "Blank Transfer of Medical Records Form," complete the form, and either mail or fax the form to our office. Please note that for routine records request, requests will be completed within seven to ten business days. For urgent records request, we prioritize and process each urgent request on a case-by-case basis. Please complete and send the form to us, and contact our office if your records request is of an urgent nature.

ADD/ADHD Information and Evaluation

How do I get my child evaluated for Attention Deficit and Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

The first step in getting your child evaluated for Attention Deficit and Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) is to talk with your child’s teachers at school and see if their concerns match with your concerns on his/her behavior at home.
- Parent Questionnaire Form
- Teacher Questionnaire Form

You should print off a parent form for each caregiver at home to fill out.

Print off a teacher forms for two teachers that teach academic subjects to fill out the forms. Also, try to get a teacher that works with the child during the morning and one that works with the child during the afternoon to fill out the forms if possible. If your child only has one main teacher, one teacher evaluation will suffice.

Return the forms to your physician by dropping them off at the office, by mail, or by fax (addresses and phone numbers are at the top of the page). Note, it may be easier for the parent to collect the forms from the teachers and return all of the forms together at once.

After the forms are returned to the physician, call and set up a “Conference” visit. At Pediatrics East, these conferences are usually the last appointment in the morning (11:30AM) or the last appointment in the afternoon (4:30PM). Please note that no conference appointments are available on Friday afternoons.

During your conference visit, the physician will discuss with you and your child what concerns you have, will discusses the results of the evaluation forms, and address whether or not your child has ADD/ADHD.

Additional ADHD Information can be found in the here.

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