Patient Forms

Forms to Download and Print

All forms must be returned to us by the patient/signer in person.

General Forms:

Sliding Scale Application

New Patient Registration

Permission to Share My Personal Health Information

Permission to Release Medical Records

Patient Complaint Grievance

Parental Consent Form for Elsie Allen

Rights Responsibilities Grievance

HIPAA Notice of Privacy Practices rev 2022 

 

Visit Specific Forms

Tele-Dental Visit Instructions

Well-Child Baby Visit

 

Well-Child Baby Visits:

2-Month Visit:

• Well-child survey for 2-month visit

4-Month Visit:

• ACES/PEARLS
• Well-child survey for 4-month visit

6-Month Visit:

• No forms needed

9-Month Visit:

• ACES/PEARLS
• Well-child survey for 9-month visit

12-Month Visit:

• ACES/PEARLS
• Well-child survey for 12-month visit
• Ages and Stages (ASQ)

15-Month Visit:

• Well-child survey for 15-month visit
• Ages and Stages (ASQ)

18-Month Visit:

• Well-child survey for 18-month visit
• Ages and Stages (ASQ)
• MCHAT

2 Year/ 24-Month Visit:

• ACES/PEARLS
• Well-child survey for 24-month visit
• Ages and Stages (ASQ)
• MCHAT