Patient Forms

Policies

• Financial policy-VP1 2022
• Policy Forms 2022
• Appointment Policy
• Notice of Privacy Practices
• Walk-In
• Authorization for release of Medical Records
• Fluoride Varnish
• Telemedicine Consent

Patient Forms

We are happy to provide our office forms for convenient download on your home computer. Please print and complete the forms below, and bring them with you to your child's first appointment. Questions about which forms you need? Please call our office and our courteous staff will assist you in preparing for your child's first visit.

First Appointments:

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

Check Ups:

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

Behavior Appointments:

The doctors may have assigned questionnaires through the Valley Pediatrics Patient Portal. Please check the portal and fill out the requested surveys. You do not have to complete the forms below if you have already completed them through the portal.

• Vanderbilt Parent Initial
• Vanderbilt Parent Follow-Up
• Vanderbilt-Teacher

Flu Clinic Visits:

• Flu Signature Sheet
• Drive-Thru Flu Clinic Instructions

Walk-In Monday - Friday Mornings (ON HOLD at this time):

• Walk-In

COVID VACCINE:

• COVID EUA Sheet
• COVID Signature Sheet