Office Forms
Save time during your child's first visit by having this insurance information form, a medical history form, office policies, and the consent form below completed for each new patient. You may bring completed forms with you to the office or fax them to us before your appointment.
For requesting your child's medical records from Milestones Pediatrics.
HIPAA Notice Of Privacy Practices
Read the above notice of privacy practices, and bring in a signed consent form on your child's first visit.
Please complete one medical history form for each new patient, and bring it in on your first visit.
Release of Medical Information Form
Complete this form if you want your child's medical records to be sent here from another office or facility.
Newborn Screening Results Request Form
Complete this form before your infant's first visit to help us obtain his or her newborn metabolic screening results.
Bring this in for your child's check-up if s/he attends or will soon attend school or daycare.
Please complete all questions on the first page. Write your child's name and DOB on all pages. Bring this in for your child's check-up appointment if he or she is 11 years of age or older.
Please complete this online questionnaire prior to your child’s scheduled checkup/well-child visit for all children from ages 4 months through 4 years.
Bring this completed questionnaire to your appointment for possible concussion.
This screener is to be completed for all checkups at ages 5 years to 18 years.
Postpartum Depression Screener
This questionnaire is to be completed by mothers when babies come in for their checkup at ages 1, 4, and 6 months.
This screener is to be completed for checkups at ages 18 months and 24 months.
These include symptom checklists for parents and teachers at initial evaluation and also for follow-up evaluations.
