The Pediatric Place

These forms must be complete prior to your first appointment. Depending on your first visit, you may also receive a CHADIS email or text to complete forms.

You can fax, email or drop off the forms at the office. After we create your patient records, we will call you to set your appointment:

Practice Agreement – HIPAA and Billing Policies (read only-you do not need to bring in)
Patient Contact and Consent Form (one per family)
Patient Contact and Consent Form for 18 year old (one for each patient 18 years or older to complete)
Insurance and Finance Policy (one per family, initial, sign)
Medical History (one for each child)
Request Medical Records (to request medical records from your previous pediatrician – request in advance of 1st visit)