Patient Forms

• Patient Forms, Policies, & Brochures
  • Patient Registration
  • Patient Registration 18 yrs +
  • Acknowledgement of Receipt of Notice of Privacy Practices
  • Notice of Privacy Practices
  • Office Policies
  • Payment Policies
  • Credit Card on File Policy
  • Vaccine Policy
  • 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
  • Fax Cover Sheet
  • New portal: Getting Started Guide
• School and Daycare Forms

• State of Connecticut School Form (for sports participation also)
• State of Connecticut Daycare/Preschool Form (birth to 5 years)
• Medication Authorization Form

• Medical Action Plans and Questionnaires
  • Asthma Action Plan (0-11 years) or (over 12 years)
  • Allergy Action Plan (English) or (Spanish)
  • Asthma assessment (young kids) or (older kids) (coming soon)
  • ADHD Vanderbilt Forms for Parents and Teachers - choose from below:

AAP - Vanderbilt - Parent Form
AAP - Vanderbilt - Teacher Form
AAP - Vanderbilt - Parent Follow-up Form
AAP - Vanderbilt - Teacher Follow-up Form

• 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.