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.

Please complete one medical history form for each new patient, and bring it in on your first visit.

Read the above notice of privacy practices, and bring in a signed consent form on your child's first visit.

Complete this form if you want your child's medical records to be sent here from another office or facility.

Complete this form before your infant's first visit to help us obtain his or her newborn metabolic screening results.

Please complete this online questionnaire prior to your child’s scheduled checkup/well-child visit for all children from ages 2 months through 4 years.

Please complete this two-page form and bring it along to your child's wellness appointment, for ages 11 and up.

Bring this in for your child's check-up if s/he attends or will soon attend school or daycare.

• ADHD Parent Initial Form
• ADHD Parent Follow-Up Form
• ADHD Teacher Initial Form
• ADHD Teacher Follow-Up Form

Bring this completed questionnaire to your appointment for possible concussion.

This screener is to be completed for checkups at ages 18 months and 24 months.

This screener is to be completed for all checkups at ages 5 years to 18 years.

This questionnaire is to be completed by mothers when babies come in for their checkup at ages 1, 4, and 6 months.

For requesting your child's medical records from Milestones Pediatrics.

• MCHAT
• SCARED Anxiety Screen (parents to complete)
• Edinburgh Postnatal Depression Scale
• GAD-7
• SCARED Anxiety Screen (child to complete)
• PSC-17
• PHQ-9 (Modified for Teens)
• PHQ-9 (Adult)