Pediatric Associates of Richmond

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Forms

Before your first visit

The following forms are necessary prior to your initial visit. For your convenience, we have provided them here on our website so that you may have them ready at the time of your first visit.

Pediatric Associates Patient Information Sheet
Records Release from Previous Doctor
Notice of Privacy Practice

Important Information

The following forms are informational. The first describes our policy concerning patient forms and the second is an informational reminder to new parents about adding a new child to an insurance policy.

Form Policy Handout
Newborn Insurance Reminder for New Parents
Medical Records Policy
HIPAA Records Release Form
18 Year Old Consent

Clinical Forms

Our providers may direct you to one or more of the following forms to aid in the diagnosis and/or treatment of various clinical situations.

Autism Screening Questionnaire: M-CHAT
Depression Screening Questionnaire: PHQ9
ADHD Questionnaire: Vanderbilt parent (initial)
ADHD Questionnaire: Vanderbilt teacher (initial)
Vomiting & Diarrhea Management and Hydration Tips
Tick Bites
Bat Exposure
Lice

School Forms

State School Physical Form
VHSL Sports Physical Form

Flu Season Information

The following are forms concerning our flu season vaccination services. There are informational packets as well as consent forms for both types of vaccine.

Quadrivalent Flu Vaccine Waiver 2016-2017
FluZone CDC Info Sheet (VIS)

*As of January 1, 2009, we will start charging $5.00 to complete all school, college and camp forms for our patients. The charge will be for each form requested and payment will be collected before the form is completed. We require between 3-5 business days to complete the forms. You may then either pick them up at the office of your choice or provide us with a self addressed stamped envelope for mailing. You will need to complete a HIPAA release form if you want us to mail the form anywhere other than your home address. Please be aware that if the form has specific lab requirements or immunizations you need to make sure these have been met before we can even complete the form. A delay in obtaining lab work will of course increase the time frame to complete your forms.