Pediatrics Forms

Electronic Forms

New Patient Registration Forms (To be used for televisits only): These forms give us permission to treat your child as well as your consent for us to provide telemedicine services. They also provide us with the information necessary to properly create your child’s chart.

New Patient Registration Forms (NORRIS SQUARE): These forms are only to be used by patients at our Norris Square satellite clinic. 

Release of Information Form – This form gives us permission to communicate with other medical professionals or school officials about your child. It also gives us permission to see your previous records.  

Unaccompanied Minors form – This form is for parents of children ages 13 and above who are allowed to come to the clinic by themselves. The parent must give us permission to treat the child. 

Designated Agents – This form allows the parent or legal guardian to give permission to another person (such as a grandparent, step-parent, uncle, aunt, sibling or family friend) to bring your child to an appointment. 

Document upload page- This page allows you to safely and securely send important documents to us (such as your child’s insurance card, your ID, and proof of income to quality for our sliding fee scale)

Behavior questionnaire (Parent Version):  These questions are to be completed by parents of children with behavior concerns. It helps us figure out exactly what types of issues your child has and how it affects them. This questionnaire is long and will take about 20 minutes. It’s important to ask so many questions because we want to make the correct diagnosis. 

Behavior Questionnaire (Teacher Version) – This questionnaire is for TEACHERS of children who are having trouble with their learning or behavior in school. It should take no more than 10 minutes to complete. 

Anxiety Questionnaire (SCARED) – This is a questionnaire for the parents of children with anxiety. There are many different types of anxiety. This helps us figure out which specific type of anxiety your child has. 

Paper Forms

Behavioral Health Screening Forms

Vanderbilt – This is a tool that is used to screen for ADHD whenever there are behavioral concerns. There is a version for parents and another version for teachers.

SWYC – This screens for your child’s developmental abilities and behaviors, as well as the well-being of the parents.

PSC Y and PSC – We use this tool to screen for behavior problems in children and adolescents beginning at age 6.

SCARED – This is a tool that we use to screen for anxiety in children and adolescents.

PHQ-9 – We use this questionnaire to screen for depression in children and adolescents.

School and Daycare Forms

Philadelphia School District Physical form – This form is required annually for all children entering the Philadelphia School District.

Daycare form – This form is required for children entering child care (such as daycare, preschool and Pre-K).

School Medical Administration forms – Some patients may need the school nurse to administer a child’s medication while at school (e.g. a child which asthma who needs albuterol). In these cases this form must be completed by a medical provider.

PIAA – This is the form that the Philadelphia school district requires for all youth who are participating in sports. Be sure you complete sections 3, 4 and 5 BEFORE asking us to complete section 6.

Other

Driver’s Learner’s Permit application – All applications to obtain a learner’s permit from PENNDOT require the medical provider to complete a part of this form.

Spotlight On

Karam Mounzer, MD

Dr. Mounzer identified two major gaps in the care of patients with HIV/hepatitis C (HCV) co-infection, and the complexity of multidrug-resistant HIV treatment. He is involved with many clinical trials focusing on drug development and better understanding of HIV immunopathogenesis with the Wistar Institute. He is involved in teaching and mentoring.

Learn More about Spotlight On
Dr. Karam Mounzer

Dr. Mario Cruz

Dr. Mario CruzDr. Cruz is a board certified pediatrician who serves as the Medical Director for our Pediatrics and Adolescent Health Center. He has presented and/or published in the fields of community violence and domestic violence prevention, quality improvement, behavioral health, curriculum development and mentorship. In 2019 he received the Greater Philadelphia Social Innovation Award for Innovations in Healthcare.


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