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.
- Patient Forms & Brochures (NP: indicates necessary forms for new patients)
- Patient Registration NP
- Pediatric Health History Form NP
- Acknowledgement of Receipt of Notice of Privacy Practices NP
- Notice of Privacy Practices NP
- Authorization to Release Medical Records: use this form when transferring into or out of our practice OR if we need to get information from an outside source (school, specialist, etc.)
- Authorization for Child to Receive Care: use this form if a non-parent, non-guardian adult will be accompanying your child when you are away or working
- Transition to Adult Care Brochure: a guide for teenagers as they start thinking about their eventual transition to adult care
- Office Policies & Forms
School and Daycare Forms
NOTE: Please fill out parent section of form before giving it to us for review/completion. Thank you!!
- State of Connecticut School Form (for sports participation also)
- State of Connecticut Daycare/Preschool Form (birth to 5 years)
- School Medication Authorization Form (BLANK, Albuterol, Acetominophen, Ibuprofen, Benadryl, EpiPen) (coming soon)
- Daycare Medication Authorization Form
- Medical Action Plans and Questionnaires
- MCHAT - Autism screening questionnaire given at 18 month well child check: English or Other languages
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.