Patient Forms

New Patients

A registration form is required each year to obtain current information for patients and parents.

This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.

Please complete this form to notify us as to the individuals who may bring your child to the office for treatment. Without this form, we will be unable able to deliver medical service to your child if he or she is accompanied by someone other than the listed parent(s)/legal guardian.

If you are new to PHCA and your child is age 6 months or older please bring this completed form to your child's first visit at our office.

For all new patients. Please bring the completed form to your child's first visit at our office

For parents-to-be who would like a prenatal visit and introduction, please complete this short questionnaire to help us get to know you.

This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.

If you are a new patient, we will ask you to read and sign a Privacy Notice. To save you time in the office, please read and sign this document. Bring only the signed last page with you to your appointment.

Please complete this form to have your child's medical records released to our office, from your child's previous health care provider.

Established Patients

A registration form is required each year to ensure current information is on file.

This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.

Please fill out this form to have your child's medical records released FROM Pediatric Health Care Alliance to another doctor or medical facility.

If there are any changes to the individuals who have your permission to bring your child(ren) into the office for care, please complete this form.

This form contains detailed billing policies and a representative list of items with potential fees and charges, to ensure you are better informed at the time of services and prior to the arrival of a billing statement. A completed form is required each year.

Privacy Notice

Click here to read.
Our complete notice is available for your review. A parent/guardian will be asked to sign off on receipt of this notice at the first visit each year, on the Billing Guarantor Signoff form.

Developmental Screenings

Please complete these questionnaires no earlier than 1-2 weeks prior to your appointment. This timing is important to have a clear picture of your baby's development close to the scheduled visit.
(Please write your child's name and date of birth in the "Notes" section on the first page.)

Please complete these questionnaires no earlier than 1-2 weeks prior to your appointment. This timing is important to have a clear picture of your child's development close to the scheduled visit.
(Please write your child's full name and date of birth in the "Notes" section on the first page.)

Vaccines

Please complete this form to authorize the Alliance to administer the influenza vaccine to your child. Prior to signing this form, you will need to read the Vaccine Information Statement from the Centers for Disease Control and Prevention.

If your child is scheduled for a vaccine-only visit for any immunization, please bring this completed form to the visit.

Physicals

If your adolescent child has an appointment with one of our pediatricians, please print and complete this form. Your child will also need to complete the "patient adolescent form" listed below.

When our pediatricians see adolescent patients, we request the adolescent complete a short confidential questionnaire. Please print this form and have your child complete it before his or her appointment. Your child can give the form directly to the pediatrician to protect his or her feeling of confidentiality. If you have any questions regarding this form, please do not hesitate to contact your office.

Please have your child complete this form prior to his or her scheduled sports physical.

ADD/ADHD

Form 1 of 2 Parents should print and complete this form prior to your child's appointment for evaluation of ADD/ADHD. Please bring both completed forms to your appointment.

Form 2 of 2 Parents should print and have your child's teacher complete this form prior to your child's appointment for evaluation of ADHD. Please bring both completed forms to your appointment.

Form Form 1 of 2 Complete these forms only if your pediatrician requests them for a follow up visit.

Form Form 2 of 2 Complete these forms only if your pediatrician requests them for a follow up visit. (Updated 9/19/2012)

This form will be provided to you at the time of prescription refill for ADD - ADHD medication(s). This states our policy regarding follow up and monitoring of your child's status, based on medical industry and health insurance quality care standards.

Weight Management

After your child's initial Weight Management visit, a follow-up visit will be scheduled. Please bring this completed questionnaire with you.

This diary is to help keep track of your meals, water, physical activity, and screen time to help everyone follow the guidelines for a healthy family. Please use this diary each week, and bring completed diaries to your child's weight management visit.

If your pediatrician schedules a Weight Management visit, please bring this completed questionnaire with you.

Asthma

This form is used to assess your child's level of asthma. Please complete it before your next appointment and ask the office staff to place it in your child's chart. The pediatrician or nurse practitioner will review the questionnaire with you.

Billing

This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.

If you need a copy of your child's medical records for any reason, please review and complete this form and turn it in at your pediatrician's office.