Forms

Complete most of your forms online prior to your child being seen. If you’re a new patient, your first step is to complete the Family History Form and the age-specific well child exam form below.

New Patient Forms

The Family History Form is for new patients joining the Central Priority Pediatrics family. Please see the New Patient Guide for additional details.

• Family History Form

General Clinic Forms

This section contains required forms related to consent for medical services, medical records release from a previous doctor, financial policies and more.

• General Consent Form
• Medical Records Release Form
• Financial Policy & HIPAA

Well Child Exam Forms

Please complete an age-appropriate form prior to your well-child exam appointment. We ask that you complete these forms no sooner than 2 weeks prior to your appointment.

• Newborn
  
• 1 month
  
• 2 month
  
• 4 month
  
• 6 month
  
• 9 month
  
• 12 month
  
• 15 month
  
• 18 month
  
• 2 year
  
• 30 month
  
• 3-5 year
  
• 6-8 year
• 9-10 year

2 questionnaires will be completed at ages 11-17 (one for the parent to complete and one for the patient to complete).

• Patients age 11-12:     Parent questionnaire     Patient questionnaire
• Patients age 13-17:     Parent questionnaire      Patient questionnaire
• Patients age 18+:        Patient questionnaire

Asthma Forms

• Asthma control test (ages 4-11)
• Asthma control test (age 12+)

Mental Health and ADHD Forms

When your child joins the mental health program at Central + Priority Pediatrics, we’ll need additional information from you. Start with the Mental Health Intake Form and complete the ADHD forms if that is the diagnosis. Learn more on the Services page.

• Mental Health/ADHD Intake Form
• ADHD Medical Follow-up Form
• ADHD Medication Refill Request