This form acknowledges your child's patient confidentiality rights, and parents should complete this form for adolescent patient visits (ages 12-18 years).

When our pediatricians see adolescent patients, we request that the patient complete a short, confidential questionnaire. Adolescent patients can give a completed questionnaire directly to the pediatrician to protect his or her feeling of confidentiality, or the form can be provided for completion during the visit. Confidentiality is promised to adolescent patients as part of our working relationship. We do encourage patients to discuss these issues openly with their families. We will inform a parent or guardian if a patient poses a serious risk to themselves or to others. 

Please have this form completed prior to a scheduled sports physical.