Patient Forms<\/h1><\/div><\/div><\/div><\/div><\/div>Our patient forms are here for you should you ever need them. You will have the ability to complete registration and required forms electronically through Phreesia during appointment check-in, as well.<\/p>\n<\/div><\/div><\/div>
General Forms<\/h3><\/div>\n- Immunization Policy<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n<\/ul>\n<\/div>
Medical Information Forms<\/h3><\/div>\n- Patient Medical History and Registration Form<\/a><\/li>\n
- Child Family History<\/a><\/li>\n
- Tuberculosis Screening Questionnaire<\/a><\/li>\n
- Sports Physical Form<\/a><\/li>\n<\/ul>\n<\/div>
HIPAA Forms<\/h3><\/div>\n- HIPAA Notice of Privacy<\/a><\/li>\n
- Privacy Notice and Consent to Treat Acknowledgment and Financial Policy Agreement<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n
- Medical Record Release<\/a><\/li>\n
- Email Consent<\/a><\/li>\n<\/ul>\n<\/div>
Developmental Screening Forms<\/h3><\/div>\n- ASQ- 8-9 Months<\/a><\/li>\n
- ASQ-24 months<\/a><\/li>\n
- ASQ-30 Months<\/a><\/li>\n
- Brief Early Childhood Screening Assessment (ECSA)<\/a><\/li>\n
- MCHAT (Autism screen)<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Well Visit Anticipatory Guidance Sheets<\/h3><\/div>\n- HOSPITAL FOLLOW UP VISIT SHEET<\/a><\/li>\n
- 2 WEEK VISIT SHEET<\/a><\/li>\n
- 1 MONTH VISIT SHEET<\/a><\/li>\n
- 2 MONTH VISIT SHEET<\/a><\/li>\n
- 4 MONTH VISIT SHEET<\/a><\/li>\n
- 6 MONTH VISIT SHEET<\/a><\/li>\n
- 9 MONTH VISIT SHEET<\/a><\/li>\n
- 12 MONTH VISIT SHEET<\/a><\/li>\n
- 15 MONTH VISIT SHEET<\/a><\/li>\n
- 18 MONTH VISIT SHEET<\/a><\/li>\n
- 2 YEAR VISIT SHEET<\/a><\/li>\n
- 2 1\/2 YEAR VISIT SHEET<\/a><\/li>\n
- 3 YEAR VISIT SHEET<\/a><\/li>\n
- 4 YEAR VISIT SHEET<\/a><\/li>\n
- 5 YEAR VISIT SHEET<\/a><\/li>\n
- 6-11 YEAR VISIT SHEET<\/a><\/li>\n
- 12-15 YEAR VISIT SHEET<\/a><\/li>\n
- 16-17 YEAR VISIT SHEET<\/a><\/li>\n
- 18 YEARS AND OLDER<\/a><\/li>\n<\/ul>\n<\/div>
Clinical Information Handouts<\/h3><\/div>\n- Helpful Hints for Feeding Your Baby<\/a><\/li>\n
- Healthy Eating For Children<\/a><\/li>\n
- Valuable Resources for Breastfeeding Moms<\/a><\/li>\n
- How to Feed a Picky Toddler- Child<\/a><\/li>\n
- CDC Immunization Information Sheets<\/a><\/li>\n
- Adult Special Needs Resources<\/a><\/li>\n
- Evaluation and Management of Suspected Speech Delay in Toddlers<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Depression & Anxiety Forms<\/h3><\/div>\n- Anxiety Screen- SCARED (parent completion)<\/a><\/li>\n
- Anxiety Screen- SCARED (child completion)<\/a><\/li>\n
- Postpartum Depression Screen<\/a><\/li>\n<\/ul>\n<\/div>
ADHD Forms and Questionnaires<\/h3><\/div>\n- ADHD Initial Visit Evaluation Forms – Parent<\/a><\/li>\n
- ADHD Initial Visit Evaluation Forms – Teacher<\/a><\/li>\n
- ADHD self-reporting forms for teens and young adults<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Parent<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Teacher<\/a><\/li>\n<\/ul>\n<\/div>
Weight Management<\/h3><\/div>\n- Kids Start Food Plan (PDF)<\/a><\/li>\n
- That-a-Weigh Kids\u2122 Food List (PDF)<\/a><\/li>\n
- Kids Count Weekly Planner<\/a><\/li>\n
- <\/li>\n<\/ul>\n<\/div><\/div><\/div>
Letter\/ Forms Completion<\/h2><\/div>We will gladly fill out required forms for your child at his or her well checkup at no charge. However, if you need any forms or letters completed outside of your scheduled well-child appointment, there will be a fee per child. The Carithers Pediatric Group reserves the right to modify these charges from time to time at our discretion. If a type of form presented for completion is not included in this list, we reserve the right to apply a fee that we deem appropriate.<\/p>\n
An additional fee of $5.00 will be charged if the forms are sent to us by email to complete or if the office has to email, mail or fax the forms to the parent. If forms are picked up and dropped off, no additional fee will be charged.<\/p>\n
\n- FMLA\/ Disability Forms: $30.00<\/li>\n
- Typed Letters: $20.00<\/li>\n
- Shot Records: $10.00<\/li>\n
- College Forms: $10.00<\/li>\n
- Camp Forms: $10.00<\/li>\n
- Physical Forms: $10.00<\/li>\n
- Sports Forms: $10.00<\/li>\n
- Overseas\/ Travel Forms: $10.00<\/li>\n
- Notarized Forms: $15.00<\/li>\n<\/ul>\n<\/div><\/div><\/div><\/div><\/div>
Need More Information?
\nWe Are Here to Help<\/span><\/h2>\n<\/div>
Our patient forms are here for you should you ever need them. You will have the ability to complete registration and required forms electronically through Phreesia during appointment check-in, as well.<\/p>\n<\/div><\/div><\/div>
General Forms<\/h3><\/div>\n- Immunization Policy<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n<\/ul>\n<\/div>
Medical Information Forms<\/h3><\/div>\n- Patient Medical History and Registration Form<\/a><\/li>\n
- Child Family History<\/a><\/li>\n
- Tuberculosis Screening Questionnaire<\/a><\/li>\n
- Sports Physical Form<\/a><\/li>\n<\/ul>\n<\/div>
HIPAA Forms<\/h3><\/div>\n- HIPAA Notice of Privacy<\/a><\/li>\n
- Privacy Notice and Consent to Treat Acknowledgment and Financial Policy Agreement<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n
- Medical Record Release<\/a><\/li>\n
- Email Consent<\/a><\/li>\n<\/ul>\n<\/div>
Developmental Screening Forms<\/h3><\/div>\n- ASQ- 8-9 Months<\/a><\/li>\n
- ASQ-24 months<\/a><\/li>\n
- ASQ-30 Months<\/a><\/li>\n
- Brief Early Childhood Screening Assessment (ECSA)<\/a><\/li>\n
- MCHAT (Autism screen)<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Well Visit Anticipatory Guidance Sheets<\/h3><\/div>\n- HOSPITAL FOLLOW UP VISIT SHEET<\/a><\/li>\n
- 2 WEEK VISIT SHEET<\/a><\/li>\n
- 1 MONTH VISIT SHEET<\/a><\/li>\n
- 2 MONTH VISIT SHEET<\/a><\/li>\n
- 4 MONTH VISIT SHEET<\/a><\/li>\n
- 6 MONTH VISIT SHEET<\/a><\/li>\n
- 9 MONTH VISIT SHEET<\/a><\/li>\n
- 12 MONTH VISIT SHEET<\/a><\/li>\n
- 15 MONTH VISIT SHEET<\/a><\/li>\n
- 18 MONTH VISIT SHEET<\/a><\/li>\n
- 2 YEAR VISIT SHEET<\/a><\/li>\n
- 2 1\/2 YEAR VISIT SHEET<\/a><\/li>\n
- 3 YEAR VISIT SHEET<\/a><\/li>\n
- 4 YEAR VISIT SHEET<\/a><\/li>\n
- 5 YEAR VISIT SHEET<\/a><\/li>\n
- 6-11 YEAR VISIT SHEET<\/a><\/li>\n
- 12-15 YEAR VISIT SHEET<\/a><\/li>\n
- 16-17 YEAR VISIT SHEET<\/a><\/li>\n
- 18 YEARS AND OLDER<\/a><\/li>\n<\/ul>\n<\/div>
Clinical Information Handouts<\/h3><\/div>\n- Helpful Hints for Feeding Your Baby<\/a><\/li>\n
- Healthy Eating For Children<\/a><\/li>\n
- Valuable Resources for Breastfeeding Moms<\/a><\/li>\n
- How to Feed a Picky Toddler- Child<\/a><\/li>\n
- CDC Immunization Information Sheets<\/a><\/li>\n
- Adult Special Needs Resources<\/a><\/li>\n
- Evaluation and Management of Suspected Speech Delay in Toddlers<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Depression & Anxiety Forms<\/h3><\/div>\n- Anxiety Screen- SCARED (parent completion)<\/a><\/li>\n
- Anxiety Screen- SCARED (child completion)<\/a><\/li>\n
- Postpartum Depression Screen<\/a><\/li>\n<\/ul>\n<\/div>
ADHD Forms and Questionnaires<\/h3><\/div>\n- ADHD Initial Visit Evaluation Forms – Parent<\/a><\/li>\n
- ADHD Initial Visit Evaluation Forms – Teacher<\/a><\/li>\n
- ADHD self-reporting forms for teens and young adults<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Parent<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Teacher<\/a><\/li>\n<\/ul>\n<\/div>
Weight Management<\/h3><\/div>\n- Kids Start Food Plan (PDF)<\/a><\/li>\n
- That-a-Weigh Kids\u2122 Food List (PDF)<\/a><\/li>\n
- Kids Count Weekly Planner<\/a><\/li>\n
- <\/li>\n<\/ul>\n<\/div><\/div><\/div>
Letter\/ Forms Completion<\/h2><\/div>We will gladly fill out required forms for your child at his or her well checkup at no charge. However, if you need any forms or letters completed outside of your scheduled well-child appointment, there will be a fee per child. The Carithers Pediatric Group reserves the right to modify these charges from time to time at our discretion. If a type of form presented for completion is not included in this list, we reserve the right to apply a fee that we deem appropriate.<\/p>\n
An additional fee of $5.00 will be charged if the forms are sent to us by email to complete or if the office has to email, mail or fax the forms to the parent. If forms are picked up and dropped off, no additional fee will be charged.<\/p>\n
\n- FMLA\/ Disability Forms: $30.00<\/li>\n
- Typed Letters: $20.00<\/li>\n
- Shot Records: $10.00<\/li>\n
- College Forms: $10.00<\/li>\n
- Camp Forms: $10.00<\/li>\n
- Physical Forms: $10.00<\/li>\n
- Sports Forms: $10.00<\/li>\n
- Overseas\/ Travel Forms: $10.00<\/li>\n
- Notarized Forms: $15.00<\/li>\n<\/ul>\n<\/div><\/div><\/div><\/div><\/div>
Need More Information?
\nWe Are Here to Help<\/span><\/h2>\n<\/div>
- \n
- Immunization Policy<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n<\/ul>\n<\/div>
Medical Information Forms<\/h3><\/div>
- \n
- Patient Medical History and Registration Form<\/a><\/li>\n
- Child Family History<\/a><\/li>\n
- Tuberculosis Screening Questionnaire<\/a><\/li>\n
- Sports Physical Form<\/a><\/li>\n<\/ul>\n<\/div>
HIPAA Forms<\/h3><\/div>
- \n
- HIPAA Notice of Privacy<\/a><\/li>\n
- Privacy Notice and Consent to Treat Acknowledgment and Financial Policy Agreement<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n
- Medical Record Release<\/a><\/li>\n
- Email Consent<\/a><\/li>\n<\/ul>\n<\/div>
Developmental Screening Forms<\/h3><\/div>
- \n
- ASQ- 8-9 Months<\/a><\/li>\n
- ASQ-24 months<\/a><\/li>\n
- ASQ-30 Months<\/a><\/li>\n
- Brief Early Childhood Screening Assessment (ECSA)<\/a><\/li>\n
- MCHAT (Autism screen)<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Well Visit Anticipatory Guidance Sheets<\/h3><\/div>
- \n
- HOSPITAL FOLLOW UP VISIT SHEET<\/a><\/li>\n
- 2 WEEK VISIT SHEET<\/a><\/li>\n
- 1 MONTH VISIT SHEET<\/a><\/li>\n
- 2 MONTH VISIT SHEET<\/a><\/li>\n
- 4 MONTH VISIT SHEET<\/a><\/li>\n
- 6 MONTH VISIT SHEET<\/a><\/li>\n
- 9 MONTH VISIT SHEET<\/a><\/li>\n
- 12 MONTH VISIT SHEET<\/a><\/li>\n
- 15 MONTH VISIT SHEET<\/a><\/li>\n
- 18 MONTH VISIT SHEET<\/a><\/li>\n
- 2 YEAR VISIT SHEET<\/a><\/li>\n
- 2 1\/2 YEAR VISIT SHEET<\/a><\/li>\n
- 3 YEAR VISIT SHEET<\/a><\/li>\n
- 4 YEAR VISIT SHEET<\/a><\/li>\n
- 5 YEAR VISIT SHEET<\/a><\/li>\n
- 6-11 YEAR VISIT SHEET<\/a><\/li>\n
- 12-15 YEAR VISIT SHEET<\/a><\/li>\n
- 16-17 YEAR VISIT SHEET<\/a><\/li>\n
- 18 YEARS AND OLDER<\/a><\/li>\n<\/ul>\n<\/div>
Clinical Information Handouts<\/h3><\/div>
- \n
- Helpful Hints for Feeding Your Baby<\/a><\/li>\n
- Healthy Eating For Children<\/a><\/li>\n
- Valuable Resources for Breastfeeding Moms<\/a><\/li>\n
- How to Feed a Picky Toddler- Child<\/a><\/li>\n
- CDC Immunization Information Sheets<\/a><\/li>\n
- Adult Special Needs Resources<\/a><\/li>\n
- Evaluation and Management of Suspected Speech Delay in Toddlers<\/a><\/li>\n<\/ul>\n<\/div><\/div><\/div>
Depression & Anxiety Forms<\/h3><\/div>
- \n
- Anxiety Screen- SCARED (parent completion)<\/a><\/li>\n
- Anxiety Screen- SCARED (child completion)<\/a><\/li>\n
- Postpartum Depression Screen<\/a><\/li>\n<\/ul>\n<\/div>
ADHD Forms and Questionnaires<\/h3><\/div>
- \n
- ADHD Initial Visit Evaluation Forms – Parent<\/a><\/li>\n
- ADHD Initial Visit Evaluation Forms – Teacher<\/a><\/li>\n
- ADHD self-reporting forms for teens and young adults<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Parent<\/a><\/li>\n
- ADHD Follow Up Visit Evaluation Forms- Teacher<\/a><\/li>\n<\/ul>\n<\/div>
Weight Management<\/h3><\/div>
- \n
- Kids Start Food Plan (PDF)<\/a><\/li>\n
- That-a-Weigh Kids\u2122 Food List (PDF)<\/a><\/li>\n
- Kids Count Weekly Planner<\/a><\/li>\n
- <\/li>\n<\/ul>\n<\/div><\/div><\/div>
Letter\/ Forms Completion<\/h2><\/div>
We will gladly fill out required forms for your child at his or her well checkup at no charge. However, if you need any forms or letters completed outside of your scheduled well-child appointment, there will be a fee per child. The Carithers Pediatric Group reserves the right to modify these charges from time to time at our discretion. If a type of form presented for completion is not included in this list, we reserve the right to apply a fee that we deem appropriate.<\/p>\n
An additional fee of $5.00 will be charged if the forms are sent to us by email to complete or if the office has to email, mail or fax the forms to the parent. If forms are picked up and dropped off, no additional fee will be charged.<\/p>\n
- \n
- FMLA\/ Disability Forms: $30.00<\/li>\n
- Typed Letters: $20.00<\/li>\n
- Shot Records: $10.00<\/li>\n
- College Forms: $10.00<\/li>\n
- Camp Forms: $10.00<\/li>\n
- Physical Forms: $10.00<\/li>\n
- Sports Forms: $10.00<\/li>\n
- Overseas\/ Travel Forms: $10.00<\/li>\n
- Notarized Forms: $15.00<\/li>\n<\/ul>\n<\/div><\/div><\/div><\/div><\/div>
Need More Information?
\nWe Are Here to Help<\/span><\/h2>\n<\/div>
- That-a-Weigh Kids\u2122 Food List (PDF)<\/a><\/li>\n
- ADHD Initial Visit Evaluation Forms – Teacher<\/a><\/li>\n
- Anxiety Screen- SCARED (child completion)<\/a><\/li>\n
- Healthy Eating For Children<\/a><\/li>\n
- 2 WEEK VISIT SHEET<\/a><\/li>\n
- ASQ-24 months<\/a><\/li>\n
- Privacy Notice and Consent to Treat Acknowledgment and Financial Policy Agreement<\/a><\/li>\n
- Child Family History<\/a><\/li>\n
- Parent Authorization Form<\/a><\/li>\n<\/ul>\n<\/div>
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