/Patient Forms
Patient Forms2018-11-08T21:22:46+00:00

Patient Forms

On this page you will find a complete list of our patient forms. In an effort to provide the best customer service possible, and minimize your wait time in our office, please review this list and bring in the necessary forms already completed.

To view (and print) the forms below, you will need Adobe Acrobat Reader. CLICK HERE TO DOWNLOAD.

Please select a category on the left below to view the respective forms:

ADD / ADHD / Behavior Evaluation Forms

If your child has never been diagnosed with ADD or ADHD, please complete the following paperwork prior to your child’s first appointment for this evaluation. There is a form explaining the possible need for an EKG, a medical history form, and two questionnaires. These questionnaires need to be completed, one by your child’s teacher(s), and the other by the parent(s). The more forms that are completed, the more accurate the assessment will be. Please remember to bring all of these forms with you for your visit.


ADHD Medical Bulletin

ADHD Medical History

Screen for Child Anxiety Related Disorders (SCARED)

Vanderbilt Initial Assessment – Parents

Vanderbilt Initial Assessment – Teachers


ADD / ADHD Follow-Up Forms

For ALL ADD / ADHD appointments, a teacher and parent Follow-Up Questionnaire need to be completed and brought with you to the appointment. If you do not have these forms, we will not be able to give your child the best medical care and may need to re-schedule your appointment.


Vanderbilt Assessment Follow-Up – Parent

Vanderbilt Assessment Follow-Up – Teacher

Mental Health Services

Our behavioral health integration program is aimed to streamline the care your child and family receive with the convenience of receiving services at a centrally located medical home that is comforting and familiar. Medical practices that have initiated an integrated practice receive feedback of greater satisfaction among patients and pediatricians as we are able to communicate seamlessly through existing records, referrals and follow-up. We are determined to meet the needs of our patients that have struggled to link their child’s services together.


Consent for Communication

Initial Consultation Survey

New Patient Forms

In order to help speed up the process of checking in your child for his/her first visit with us, it will be helpful to print out the following forms at home and complete them prior to your visit with us.


Patient Intake form

ACE Patient

ACE Caregiver

Consent to Treat

Policy for Divorced and Separated Parents

HIPAA Medical Release Form

HIPAA Notice of Privacy Practice Form

HIPAA Authorization for Disclosure of Information Form

Patient Contract Form

Patient’s Financial Responsibility Disclosure


Additional New Patient Forms (Newborns)

For parents of newborns, please print out the following important information about pertussis, or whooping cough. If you are interested in getting vaccinated, let the front desk know when you check your infant in for his/her first exam in our office.


Pertussis Vaccine for Families of Infants

Tetanus, Diphtheria, and Pertussis Vaccine (Tdap) Consent

School Sports Physical Forms

The different counties served by Palm Beach Pediatrics each have their own specific form for school sports physicals. As these forms change annually, we have provided you a direct link to these respective forms. Please choose the county school district your child is enrolled in, print the form, and bring it with you to your appointment. Unfortunately, we are not aware of the Martin County school district having any sports physical forms online.


Palm Beach County

Please click on FORMS SEARCH in the main menu bar at the top of the page.  In the dropdown entitled, “FORM NAME”, please find the form you are seeking under ATHLETIC ELIGIBILITY.

St. Lucie County

Please scroll down the page, almost to the bottom, and find the section in the center column entitled, “ATHLETIC RESOURCES”.  Select the respective packet of forms dependent on the age of your child.

Well Visit Forms (2 wks – 6 mos)

Maternal postpartum depression screening for mothers with children 2 weeks to 6 months of age. Please print and complete this form and bring it with you on the day of your appointment.


Edinburgh Postnatal Depression Scale (EPDS)


Well Visit Forms (18 mos – 2 yr)

18 month and 2 year Check-Ups – The M-CHAT is a screening test for Autism that we perform at these two visits. Please print and complete this form and bring it with you on the day of your appointment.


Modified Checklist for Autism in Toddlers (M-CHAT)


Well Visit Forms (4 yr – 11 yr)

We are screening for behavior issues with the Pediatrics Symptom Checklist for all children ages 4-11 year olds. Please complete prior to the well visit and the screening will be discussed with you by the provider. This form is to be filled out by the PARENT.


Pediatric Symptom Checklist (PSC-17)


Well Visit Forms (12 yr +)

We are screening for depression with the PHQ-9 in all teens from ages 12 and up. Please complete prior to the well visit and the screening will be discussed with you by the provider. This form is to be filled out by the CHILD.


Patient Health Questionnaire (PHQ-9)

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October 26th, 2018|0 Comments

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