Pediatric (<18 yo) Patient Registration Forms (only to be used during downtime) These forms give us permission to treat your child. They also provide us with the information necessary to properly create your child’s chart. We only use this form when our EMR system is down.
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. It gives the child permission to come to our clinic by themselves, without a parent or guardian.
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 insurance card, vaccine records, your ID, and other confidential information)
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 will take about 20 minutes. It’s important to ask so many questions because we want to be as accurate as possible when we make 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.
Testosterone Therapy Consent Form This form will help you understand the benefits and the potential risks of testosterone therapy. If you still have questions after reading the consent form, please reach out to your medical provider.
Estrogen and Androgen Blocker Therapy Consent Form This form will help you understand the benefits and potential risks of therapy with estrogen and androgen blocker therapy. If you still have questions after reading the consent form, please reach out to your medical provider.
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.
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.