Forms
Pediatric Care Group requests that patients fill out appropriate forms prior to their scheduled visit.
You can find our forms on this page to download and complete as directed by a member of our team.
Pediatric Care Group prides itself on being able to provide high quality medical care to its patients. In an effort to be more efficient and maximize patient satisfaction during office visits, PCG requests that patients fill out appropriate forms prior to their scheduled visit.
Click Here to view PCG’s Notice of Privacy Practices
PLEASE PRINT AND FILL OUT FORMS PRIOR TO VISIT
*Please Remember to Bring Completed Forms With You to Your Scheduled Appointment*
Instructions:
New Patients Must Complete and Sign New Patient Visit Forms.
New Patients Being Seen for a Wellness Visit Must Complete and Sign New Patient Visit Forms and Wellness Visit Forms.
Patient Over 18 Years Old:
Patients who are over 18 years old may give PCG physicians and medical staff the authorization to speak with parents, guardians or other individuals regarding their healthcare.
Click Here To Download The 18 Year Old Medical Consent Form
New Patient Registration
Initial History Questionnaire
Family History Questionnaire
Acknowledgement of Privacy Practices and Policies
Acknowledgement of Appointment
Cancellation/No Show Policies
Medical Release Form
Consent By Proxy Form
Assignment of Benefits Form
Download Here
Newborn Wellness Visit
Please bring your Newborn Hospital Discharge Summary to your appointment along with the New Patient Forms
2 Month Wellness Visit
Family History Form
2 Month Wellness Visit Questionnaire
Download Here
4 Month Wellness Visit
Family History Form
4 Month Wellness Visit Questionnaire
Download Here
6 Month Wellness Visit
Family History Form
6 Month Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
Download Here
9 Month Wellness Visit
Family History Form
9 Month Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
Download Here
12 Month Wellness Visit
Family History Form
12 Month Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
TB Risk Assessment Questionnaire
Download Here
15 Month Wellness Visit
Family History Form
15 Month Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
TB Risk Assessment Questionnaire
Download Here
3 Year Wellness Visit
Family History Form
3 Year Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
TB Risk Assessment Questionnaire
Download Here
4 Year Wellness Visit
Family History Form
4 Year Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
TB Risk Assessment Questionnaire
Download Here
5 Year Wellness Visit
Family History Form
5 Year Wellness Visit Questionnaire
Lead Risk Assessment Questionnaire
TB Risk Assessment Questionnaire
Download Here
6 Year Wellness Visit
Family History Form
TB Risk Assessment Questionnaire
Download Here
7 Year Wellness Visit
Family History Form
TB Risk Assessment Questionnaire
Download Here
8 Year Wellness Visit
Family History Form
TB Risk Assessment Questionnaire
Download Here
9 Year Wellness Visit
Family History Form
TB Risk Assessment Questionnaire
Download Here
10 Year Wellness Visit
Family History Form
TB Risk Assessment Questionnaire
Download Here!
11-14 Year Wellness Visit
Family History Form
Teenage Questionnaire (Older Child/Younger Adolescent)
PHQ-2/9 (Adolescent Depression Screen)
TB Risk Assessment Questionnaire
Download Here
15-18 Year Wellness Visit
Family History Form
Teenage Questionnaire (Early Adolescent)
PHQ-2/9 (Adolescent Depression Screen)
TB Risk Assessment Questionnaire
Download Here
19 Year Wellness Visit
Family History Form
Teenage Questionnaire (Early Adolescent)
TB Risk Assessment Questionnaire
Download Here
Asthma Visit (4-11 Years)
Asthma Control Test Score – Form
Download Here
Asthma Visit (12+ Years)
Asthma Control Test Score – Form
Download Here
ADHD Initial Visit
Vanderbilt Assessment Form (Parent)
Download Here
ADHD Follow Up Visit
Vanderbilt Assessment Follow Up (Parent)
Vanderbilt Assessment Form (Teacher)
Download Here
At age 18, adolescents legally become adults for medical decision making purposes. We respect that many of our young adult patients choose to continue to involve their families in health care decisions. Our patients who are 18 or over must give consent via written proxy to allow PCG to discuss their medical care with family members. If the patient has a condition that prevents him/her from making health care decisions, we encourage parents/caregivers to consider options for supported decision-making.
We will collaborate with young adults and families regarding the age for transferring to an “adult provider” and recommend that this transfer occur by age 22. We will assist with this transfer process, including helping to identify a provider, sending medical records, and communicating with the provider about the unique needs of our patients. All patients must continue to have yearly physicals and medical care per PCG protocol in order to remain in the practice. We are happy to take care of our patients through college.
As always, if you have any questions or concerns, please feel free to contact us.
Please Click Here to Download PCG’s Authorization to Disclose Protected Health Information Form