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 ONE –Vaccine Information
Please read carefully.
STEP TWO – Screening 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 –
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 FOUR – Aftercare 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
Privacy Practices Acknowledgement
Patient Insurance Financial Agreement
18 Year Patient Information Forms
Sports Pre-Participation Screening
Pre-participation Physical Evaluation
Records Request
Authorization to Release Records
ADHD Behavior Checklist
Temporary Authorization to Treat
Temporary Authorization and Consent to Treat a Sick Child
Other Forms
Consent for Release of Confidential Information