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New Patient Forms
(Click the links below to download each form)

 Authorization for Release of Medical Information

 Autorización para la diseminación de la información médica

 Patient History (Children Under 2)

 Patient History (Children 2-10)

 Patient History (Children 11-17)

 Auth for Medical Treatment of Minors

 Patient Record Information

 Consent for Medical Care - Assignment of Benefits

 Formulary Benefits Consent Form

 Notice of Privacy Practices

 Patient Agreement

ImmTrac Consent form (English)

ImmTrac Consent form (Spanish)

Health Risk Assessment

Permission for Verbal Communication

 

Vanderbilt Forms
(Click the links below to download each form)

 NICHQ Vanderbilt Assessment Scale—PARENT Informant

 NICHQ Vanderbilt Assessment Follow-up—PARENT Informant

 NICHQ Vanderbilt Assessment Scale—TEACHER Informant

 NICHQ Vanderbilt Assessment Follow-up—TEACHER Informant

 

Additional Forms

• Medical Power of Attorney
• Living Will

The forms listed on this page are in PDF format and can be downloaded to your computer, printed and completed in the comfort of your home before your first visit to our clinic. Please be prepared to provide this information to our clinic along with your current insurance information. If you have any questions when filling out these forms, please do the best you can and our staff will assist you with your questions on the day of your visit.

Need Adobe Acrobat Reader?
If you do not have a copy of Acrobat Reader you can get one for free by clicking on the icon 'Get Acrobat® Reader'. This will take you to Adobe's website and enable you to download the Acrobat program to your computer.