For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.

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.

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.

Please complete this form upon registration to allow us to email or text PHI information that you may request.  

Please complete this form for your child's first office visit. 

New patients must review and acknowledge receipt of this information prior to your first visit.

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 office visit.

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

A summary of patient's rights and responsibilities, per Florida Statute 381.026

Please complete this form to consent to treatment of a minor child, and to identify 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.

For parents-to-be who would like a prenatal meeting before baby arrives, please complete this short questionnaire to help us get to know you.

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

Please complete the attached forms in preparation for your appointment with Pediatric Health Care Alliance.

Starting in early 2023, this statement will be presented to all patients as part of registration. It is our PHCA philosophy regarding the unique challenges and sensitive nature of medical care for children of divorced or separated parents. This is designed to help parents navigate these sensitive areas and avoid misunderstandings during the treatment process. 

Parents - please complete this screening if you will be receiving flu or pertussis vaccine from your child's pediatrician. 

For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.

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.

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.

Please complete this form upon registration to allow us to email PHI information that you may request.  

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.

This registration form is for patients 18 years and older or foster parents and is required each year to obtain current information for patients and parents. 

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

A summary of patient's rights and responsibilities, per Florida Statute 381.026

Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.

Please complete this form to consent to treatment of a minor child, and to identify 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.

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

Please complete these forms in preparation for your appointment with Pediatric Health Care Alliance.

Starting in early 2023, this statement will be presented to all patients as part of registration. It is our PHCA philosophy regarding the unique challenges and sensitive nature of medical care for children of divorced or separated parents. This is designed to help parents navigate these sensitive areas and avoid misunderstandings during the treatment process. 

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

If your child is age 2 years or older, he or she may be eligible to receive the intranasal flu vaccine, FluMist. If you would like your child to receive this type of flu vaccine, please complete this form for review with your pediatrician.

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.

This form provides parent consent for the adolescent questionnaire that is discussed at well visits for ages 17 years and younger.

This form is completed with parent consent at adolescent well visits for ages 17 years of age and younger.

This form is completed at well visits for ages 18 years of age and older.

Updated May 2024

Please Note: Portions of this form need to be completed by the parent and student before it can be provided to your pediatrician. Click here to learn more.

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.

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)

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.

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.

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

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

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.

Patients will need to complete this CDC screening checklist prior to receiving the COVID-19 Vaccine.
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V-safe is a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination.
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General information about the Vaccine Adverse Event Reporting Sytem
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Please note:  Motrin is not recommended for infants less than 6-months of age.