* If you are a new patient, please download and complete the forms that are starred.
*New Patient Registration form: please fill out before first visit
*Patient Medical History form: Please complete information for each child and the family
*Financial Policies: This form summarizes our practice’s financial policies, we ask each family to read and sign one annually. The is also an optional form that allows you to leave a credit card on file to pay co-pays and other charges.
*HIPAA NOTICE OF PRIVACY PRACTICES Please read this notice required by Federal law and then print and sign:
*Written Acknowledgement of Receipt of Notice of Privacy Practices to acknowledge that you have received and reviewed the above policy.
*Designation form This form allows parents/guardians to designate other adults (e.g. nannies/sitters, relatives, friends) who may bring your child into our office for treatment, give consent for treatment and discuss health issues with the doctors and staff. Parents/guardians do not need to be listed on the form. Please keep in mind that according to Federal Law and our policies, no one other than a parent or guardian may consent for treatment or receive health information from the doctors or staff without prior written authorization. Families should revise this form as needed.
Release of Patient Records form (from another practice)
Release of Patient Records form (from The Pediatric Center to another practice)
Please allow at least 1 week for processing. You can mail or fax ( 203-323-6177) this form to our office. Please note certain information regarding substance abuse treatment and counseling and reproductive health services and counseling may be contained in the medical record of a minor. Under Connecticut State law, this information cannot be released, even to the parent, without the minor’s consent. Therefore, all patients 13 years or older must sign this authorization for release of information to anyone (including parent) other than another healthcare provider.
Patient Portal Documentation:
You can print the standard Connecticut school forms and fill out the parent section prior to your child’s visit. Many camps accept the standard school form.
CT School Health Form (Blue Form)
CT Daycare Nursery School Health Form (Yellow)
Stamford High School Sports
Darien High School Sports Form
Greenwich HS Sports Form
New Canaan HS Sports form
Here is some information and screening questionnaires we use for common developmental issues. It may be helpful to print and complete some of these forms before visiting the office with concerns in these areas.
Attention Deficit Hyperactivity Disorder (ADHD)
The following information will be helpful for families of children with ADHD or considering the possibility of ADHD
The following questionnaires are helpful in establishing the diagnosis of ADHD. One set is for one or both parents or anyone providing care to the child at home, the other is for one or more teachers
We recommend screening all toddlers with the MCHAT between 15-24 months of age.
Autism Facts for Parents from AAP
MCHAT Toddler Screen for Autistic Spectrum Disorders
We maintain growth charts for each child in our electronic system. For those families that would like to follow growth at home we have Standard forms for American children (USA) as well as standard forms for some other ethnic groups and children with Down Sydrome.
Boys (0 – 3 Years) Length | Boys (0 – 3 Years) Weight | Boys (2 – 18 Years) Length | Boys (2 – 18 Years) Weight
Girls (0 – 3 Years) Length | Girls (0 – 3 Years) Weight | Girls (2 – 18 Years) Length | Girls (2 – 18 Years) Weight
We recommend families discuss specific rules with Teen drivers and be aware of current Laws regarding teen drivers. We have one version of a teen driving contract below as well as a link to Connecticut DMV