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 be aware-if you are requesting a form be completed by one of our doctors, your child must have had a physical within 12 months. Allow five business days to complete the form, there is a $15.00 fee if it is not brought at time of physical. You are welcome to drop it off, mail or email to info@valpeds.com.
For new patients, please complete the Patient Registration (for ages newborn - 17 years) and complete the policy forms below.
If this is your first visit we have this information for you.
Please review and sign the following policies:
Credit Card on File Authorization
Notice of Privacy Practices (HIPAA Consent)
Notice of Privacy Practices Acknowledgement
Consent for Treatment Form *Optional - If you want to permit 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 there is a fee of $30.00 for the first child and $20.00 for each additional child. To pick up the records the fee is $20.00 for the first child and $10.00 for each additional child.
*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
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
