Forms

patient-forms

Patient Forms

North Park Pediatrics charges for the completion of forms. The charge is $10 per form, with a maximum fee of $25 for forms submitted at one time. FMLA and disability forms are considered extensive and will cost $25 to complete. Forms will be completed within 5 business days. There is an additional $25 fee if you want the forms within 48 hours. No routine forms will be completed at the time of a visit.

This fee is not billable to your insurance and will be collected at the time of form pick up. Please be sure to complete all of the parent/child portions of the form before you hand the form to us. Please turn in the entire form. We will call you when the forms are completed.

If you prefer, you may supply us with a self addressed, stamped envelope to have the forms mailed back to you. If you choose to have the forms mailed to you, you will need to pay for the form completion prior to them being mailed out. We strongly recommend that you make copies of the forms in case you should need another copy some time in the future.

Download using the links below

How to schedule your child (age 5-11 only) for Covid Vaccine:

STEP ONEVaccine Information 

Please read carefully.

STEP TWOScreening Questionnaire

Print form

Please read the screening questionnaire carefully and mindfully answer all questions.  Remember, recommendations for you child are based on your answers to these questions.

Sign form

Bring completed form to your child’s appointment. (1 per child)

STEP THREE

Acknowledgement Form 

Print form

Please read thoroughly and carefully, this form contains a lot of important information.

Sign form

Bring signed form to your child’s appointment ( 1 per child)

STEP FOURAftercare Instructions

Please review and refer back to as needed after vaccination.

STEP FIVE – Call our office during regular business hours to schedule.

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New Patient Registration

Patient & Responsible Party Information

Notice of Privacy Practices

Privacy Practices Acknowledgement

Patient Insurance Financial Agreement

Pediatric Medical History

18 Year Patient Information Forms

Sports Pre-Participation Screening

Pre-participation Physical Evaluation

Records Request

Authorization to Release Records

ADHD Behavior Checklist

Behavior Checklist

Temporary Authorization to Treat

Temporary Authorization and Consent to Treat a Sick Child

Other Forms

Consent for Release of Confidential Information

Depression Screening Form

Telehealth Consent Form

Flu Form

Flu Consent Form