To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.
Administrative Forms
- New Patient Registration
- Release of Medical Information to Village Pediatrics (request records from prior provider so that we may continue care for the patient)
- Release of Medical Information from Village Pediatrics (request records from our office to new provider)
- Authorization for care 16 year old - Parent not attending appt (when someone other than parent brings patient to the appointment)
- Consent to treat minor child (Parent not attending appointment for patient umnder age 16)
- Happy 18th Birthday (letter with advice for new adults)
- 18 year old HIPAA Release & Authorization (This is Village Pediatrics HIPAA, not a general one)
- HIPAA Release Form
Well Child Visit Documents
- Two Week to One Month Well Child Check
- Two Month Well Child Check
- Four Month Well Child Check
- Six Month Well Child Check
- Nine Month Well Child Check
- Twelve Month Well Child Check
- Fifteen Month Well Child Check
- Eighteen Month Well Child Check
- M-CHAT Assessment (Autism Screening)
- PEDS Assessment (Global Developmental Screening)
- 5-yr Assessment
Other Handy Forms
- Immunization Action Coalition
- Preschool Children’s Medical Report
- Vanderbilt Initial- teacher
- Vanderbilt Initial- parent
- Vanderbilt FollowUp- teacher
- Vanderbilt FollowUp- parent
- Immunization Schedule
- Patient Health Questionnaire 2
- Patient Health Questionnaire 9
In order to view or print these forms, you will need Adobe Acrobat Reader installed. Click here to download it.