Patient & Family Information Financial Policy Non-Covered Services Waiver Assignment of Benefits Form Consent to Treat a Minor Simple Self-Pay Acknowledgement Acknowledgement of Receipt of Notice of Privacy-Practices

Authorization for Release of Medical Information

Behavioral Health Forms

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

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

Flu Vaccine Consent Form Flu Shot Confirmation Vaccine Information Sheet Influenza Live Intranasal Vaccine Information Sheet Influenza Inactivated

All Starr Pediatrics

Please feel free to look over these registration forms - they may not all be relevant to you. Please print out, complete and bring to your appointment, or drop off ahead of time.

Forms

We look forward to seeing you at All Starr Pediatrics.

Patient Forms

Records Requests

Behavioral Health Forms

Well Check Forms

Flu Information

Contact Us

Forms

We look forward to seeing you at All Starr Pediatrics.﻿

Patient Forms

Records Requests

Behavioral Health Forms

Well Check Forms

Flu Information

Contact Us

We look forward to seeing you at All Starr Pediatrics.