Forms
We are happy to provide our office forms here for convenient download on your home or work computer. Please print and complete the appropriate forms, and bring them with you when you visit us. Our courteous office staff is happy to help you determine which forms you need. Please call us if you have any questions!
To view these files you must have Adobe Acrobat Reader installed on your computer.
- Patient Registration Form
- For new patients and updated annually for established patients.
- Office Policies
- Please read and sign the acknowledgement on the second page for your first visit.
- HIPAA Privacy Policy
- For your personal review.
- HIPAA Acknowledgement Form
- For new patients to be signed after the HIPAA Privacy Policy has been read.
- Appointment of Agent
- Please complete and sign to allow another adult to bring your child for a visit if needed.
- Release of Medical Records
- Please complete and sign to allow us to request medical records from another care facility or office.
- Consent to Release Health Information
- Please complete this form to allow us to leave phone messages regarding your child’s health care, as well as specifying with whom we can leave this information (other family members, etc.).
- Developmental Screens - Ages & Stages Questionnaires
- A chance to play with your child and check developmental milestones! Please bring a completed Ages & Stages Questionnaire (ASQ) for the appropriate check up visit. A copy of the Modified Checklist for Autism in Toddlers (MCHAT) is included with the 24 month questionnaire. Each file is password protected for copyright purposes: please contact our office for the password if you are an established patient in our practice.
Patient Education
We have found that these handouts contain very useful and reliable information for common medical problems and questions. We hope you find them helpful, perhaps on those sleepless nights when they may be most needed. As always, do not consider these materials a substitute for a good conversation with your doctor - we are always happy to help!
- Acute Diarrhea
- Animal and Human Bites
- Asthma
- Autism
- Bed-Wetting (Nocturnal Enuresis)
- Blocked Tear Duct
- Bronchiolitis
- Chronic Diarrhea
- Colds
- Colic
- Common Newborn Rashes
- Conjunctivitis (Pink Eye)
- Constipation
- Corneal Abrasions
- Croup
- Dehydration
- Dental Trauma
- Diaper Rash
- Ear Infections
- Feeding Your Newborn
- Fever Management
- Food Poisoning
- Foreign Bodies (Swallowed Objects)
- Hand, Foot, and Mouth Disease
- Head Lice
- Head Trauma
- Immunizations (Vaccinations)
- Impetigo
- Insect Bites
- Minor Burns
- Mononucleosis
- Nightmares and Night Terrors
- Outer Ear Infection (Swimmer's Ear)
- Pinworms
- Poison Ivy
- Poisoning
- Skin Wounds
- Sleep Problems and Bedtime Issues
- Sprains and Strains
- Stye (Hordeolum)
- Sudden Infant Death Syndrome
- Thrush
Resource Links
The Internet is a valuable resource for parents and physicians alike. However, there is much misinformation on the Internet as well. Below are links to resources that we consider credible and accurate.
Healthy Children (a great parenting resource site created by the AAP!)
American Academy of Pediatrics
Centers for Disease Control
US Consumer Product Safety Commission (product recalls)
CDC: Travel Health
AAP: Car Seat Guide
AAP: Vaccine Information
CDC: Vaccine Information
The Children’s Hospital of Philadelphia: Vaccine Education Center
The Mayo Clinic
The Online Mendelian Inheritance in Man (OMIM) Database
(if you wish to research genetic disorders)
National Institutes of Health PubMed medical literature search engine
(a tutorial for which can be found here)
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Facility Links
Below are the links to the facilities we may use to provide excellent care for your child.
Children’s Medical Center of Dallas
Medical City Children’s Hospital
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