Click on the links below to view or download the PDF files for various patient forms:
Medication Dosing Charts
ADHD
If you have concerns about your child having ADD/ADHD, please contact our office for what steps you need to follow. ALL Patients must be up to date on Well Child Checks prior to submitting forms for review.
Office Forms
- Authorization to Release Records Form
- Acknowledgment of Receipt of Privacy Practices Form (HIPAA Acknowledgement)
- Notice of Privacy Practices Form (HIPAA Statement)
- M-Chat-R Form
- Office Policies Form
- Prenatal Registration Patient Form
- Consent for Patient Photo Form
- Consent to Treatment Form
- Mental Health Polices Form
Vanderbilt Scales Parent and Teacher
- NICHQ-Vanderbilt-Assessment-Scales Parent Initial
- NICHQ-Vanderbilt-Assessment-Scales Teacher Initial
Patient must be up to date on well checks prior to turning in Vanderbilt scales.
Parent/Guardian – Need at least 2 separate forms filled out independently
Teacher – Need a minimum of 2 for those 7 and under. Older children will need minimum of 3 teacher forms completed best if core classes when possible.
Vaccine Statement
We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics…