Forms

• Patient Registration Form
• Patient Past Medical History
• Family Medical History Form
• Privacy Policy
• Financial Policy
• Forms Policy
• Appointment Policy
• Signature Sheet

• Patient Registration Form
• Family Medical History Form
• Signature Sheet
• Sports & Cardiac Risk Assessment Form (kids 10 and up)

The following surveys may be required depending age:

• MCHAT
• SCARED Anxiety Screen (parents to complete)
• Edinburgh Postnatal Depression Scale
• GAD-7
• SCARED Anxiety Screen (child to complete)
• PSC-17
• PHQ-9 (Modified for Teens)
• PHQ-9 (Adult)

You will have questionnaires assigned through the Valley Pediatrics Patient Portal. Please check the portal and fill out the requested screens prior to the visit. You do not have to complete the forms below if you have already completed them through the portal. Please have each teacher fill out a Vanderbilt form.

• ADHD Teacher Initial Form
• ADHD Parent Initial Form
• ADHD Teacher Follow-Up Form
• ADHD Parent Follow-Up Form

Every fall we have several Flu Clinics. Flu clinic is for all kids 2 years old and above. We usually have both injectable and nasal (FluMist) available. We give MANY flu vaccines very quickly, so most people are in and out of the office in less than 10 minutes! Stickers included. We send out notices through the patient portal so stay tuned.

Each child will need a completed Flu Signature Form. Coming in with the form already done will allow you to skip to the front & get you out even faster.

We do not do any other vaccines and there are no patient visits at the same time. 

Please self-schedule through the patient portal. Each child needs a completed Flu Signature Sheet on arrival.