Forms

To expedite your visit, you can download our commonly used forms below:
Well Care and ASQ Forms

New Patients:

Newborn Packet
New Patient Packet

Forms Included in New Patient Packets:
Family Contact Information Sheet
Family Medical History
HIPAA Form
Patient Information Sheet
TB/Lead Questionnaire
The Youth Clinic Financial Policy

Forms to bring to ADHD appointment: 

Initial Parent Evaluation
Initial Teacher Evaluation
Follow Up Parent Evaluation
Follow Up Teacher Evaluation

Requesting Copies Of Your Child’s Medical Record
Please use the form below to request copies of your child’s medical mecords. Patients over the age of 18 must request their own medical records. Requests are typically processed within 3 business days. Please Note: A fee will be charged for printed records intended for personal, legal or insurance company use. No fee will be charged to securely email or fax records.

Click here to complete this form online.

School/Camp/Daycare:
Please note that for all school, camp, sports, daycare, and medication form requests, your child must have had a well child checkup within the past 12 months. Turnaround time is 5 business days due to our high volume of requests. If you require same-day turnaround for your child’s form completion, a $30 charge will be assessed. Just stop into one of our offices with your form and method of payment, and our administrative nurse will complete it for you as soon as possible.

To request a form, please call our administrative nurse at (970) 416-6282 or drop off your request at one of our three office locations. If you have verified the date of your child’s last well care, you may also fax your request (with return instructions) to (970) 207-9967.

If you would like to securely upload a form to our admin nurse, please use the form upload module below. Please make certain the patient and parent portions are completed in full prior to submission. Thank you.

 

Form Upload: