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FORMS


 

Mayfair Medical StaffPatient Forms

New patients will fill out several forms. You can print most of these out and bring them with you on your first visit or fill them out when you arrive at Mayfair Medical Group.

Patient-Family Information - Lists demographic information

Patient History - Lists family medical information

Consent for Medical Treatment of a Minor Child - Authorizes specific people to bring your child to Mayfair Medical Group for medical care and treatment.

Records Release Authorization Form

At each visit you will be asked to sign several forms.

Non Covered Services Statement - Sign and agree to pay for services that are not covered by your insurance company.


ADHD Forms

These are scoring sheets used to assess a child for ADHD.  These are screening tools, and as such, are only a part of the puzzle in figuring out which child might be at risk for ADHD.  The process is completed by your doctor at an office visit.  At the visit, your child's school and home history, medical history, and an exam are combined with the answers on these forms to assist in arriving at a diagnosis.

If this is the first time we are assessing your child for ADHD, you would want to print and complete the Initial Screening Forms below.  One or both parents might want to complete a form, and two or more primary teachers might be asked to complete a form as well.  The completed forms should be sent to your child's doctor in advance of the visit.

If your child's doctor needs to see how the medication is working, a follow-up form might be requested.  Parents and primary teachers should complete these forms.  The completed forms should be sent back to your child's doctor for review.  The parent and child might be asked to come to the office for a re-assessment after the forms are reviewed.