PATIENT FORMS

Valencia Pediatrics physicians understand that your time is valuable.  In order to make your visit more worthwhile, we’ve included some useful forms that you can download and prepare in advance of your appointment.

Please complete the Patient Registration (for ages newborn - 17 years) and bring the form to Valencia Pediatrics at the time of your next appointment.  Our registration staff will take it from there.

If this is your first visit we have this information for you.

Please review the following policies:

Financial Policy

Office Procedures & Policies

Credit Card on File Authorization

Notice of Privacy Practices (HIPAA Consent)

Consent for Treatment Form  *Optional - If you want to give permission for someone other than you (the legal guardian) to bring in your child for care.

MEDICAL RECORDS TRANSFER

Record Request

To have your child’s records sent to another provider.  We do charge a fee for this service. 

*For those patients 18 and over – You must complete and sign this form yourself.  If you are not transferring your records to a new provider we require that you pick them up yourself. 

Record Release

A form to send to your previous pediatrician so we can obtain records.

CHANGE OF INFORMATION

Please log into the Patient Portal to make your changes.

ADD/ADHD FORMS

If your child has not yet been diagnosed with an attention problem and you are concerned about it please print out the following forms and have the first parent and teacher forms completed for your initial consultation appointment.

     Vanderbilt Scale for Parent
     Vanderbilt Scale for Teacher