New Patient Forms

Registration Form– This form provides us with demographic information for your child, insurance information (if applicable), etc.

Medical History Form– This form provides us with a summary of your child’s past medical history.

Authorization for Release of Records TO SEEAP– This form allows us to request records from your previous providers.

Membership Agreement– We are a membership based office that provides a unique pediatric experience.  This form is the agreement that is signed for joining the membership.

ADHD Evaluations

Initial Evaluations – These forms are for evaluating your child for ADHD for the first time.  Please download and complete Parent Initial Vanderbilts (Have Each Parent Complete)  AND Teacher Initial Vanderbilt (Have each teacher complete)

Follow Up Visits – These forms are for monitoring progress of treatment and are used for follow up visits.  Please download and complete Parent Followup Vanderbilt  AND  Teacher Followup Vanderbilt.

Functional Medicine Evaluations

Comprehensive Evaluation Form– This form is a detailed history to assist our provider in getting to the root cause of what is causing your child’s symptoms.  It is not required for all new patients, only those who have a chronic illness that they wish to have a functional medicine consultation for.  We know it is long and detailed, but it is very valuable for evaluating and treating your child.  It is a fillable form, so you can complete the form and email it to us (or fax if you choose).

Forms for your Reference

Notice of Privacy Practices– this form describes how your protected health information is protected and utilized.

Vaxcare Notice of Privacy Practices – Vaxcare is a third party company that provides and bills for commercial vaccines. If you have commercial insurance (BCBS, Aetna, United Healthcare, etc), Vaxcare will be doing the billing.