Patient Forms

REGISTRATION & ADMINISTRATIVE FORMS

• New Patient Registration Forms
• Office Policies & Forms
• Medicaid Coordination of Benefits (Medicaid Insured Patients Only)

COVID-19 VACCINATION FORMS

A consent form and the prevaccination checklist are required for all COVID-19 vaccine appointments.

• Under 18 Years Vaccine Consent
• Over 18 Years Vaccine Consent
• Prevaccination Checklist

PATIENT CARE & DEVELOPMENTAL SCREENING FORMS 

• Ages & Stages Developmental Questionnaires (ASQ-3)
• Illinois School Physical Form
• IHSA Sports Pre-Participation Form 
• Childhood Lead Risk Questionnaire
• Adolescent Depression Screening (PHQ-9)
• Pediatric Symptom Checklist (PSC-17)

ADD / ADHD RATING SCALES

• Parent Questionnaire – Initial Evaluation 
• Parent Questionnaire – Follow Up
• Teacher Questionnaire – Initial Evaluation 
• Teacher Questionnaire – Follow Up