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 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.
Can’t view our forms? Download Adobe Acrobat
Please review the following policies:
Notice of Privacy Practices (HIPAA Consent)
Designee Authorization 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
- 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.
- A form to send to your previous pediatrician so we can obtain records.
Change of Information
- Haven’t seen us in two years? Please complete this form prior to your visit.
**** If your child is web enabled please use the Patient Portal to make your changes****
**** If your child is web enabled please use the Patient Portal to make your changes****