Forms and Downloads

 

Beginning September 1st 2020, POD will be charging $10 per camp form and or school form, if the form is not completed at the well child exam. If the patient form is dropped off or emailed and asked to be completed the same day, the charge will be $20 per form.

 

New Patient Forms

• New Patient Registration Form
• HIPAA – Acknowledgement of Receipt of Privacy Packages
• Medical Authorization Form
• All new patient forms
• Prenatal Visit Form

Complete an ASQ Questionnaire (Ages and Stages Questionnaire)

Please complete ASQ's in the portal!

 

Medical Records Release Forms

• Authorization for Release of Medical Records

 

Forms to Aid in Diagnosis of ADHD and Learning Differences

• Diagnostic Testing Informed Consent Form
• NICHQ Vanderbilt Assessment Form - Teacher Informant
• NICHQ Vanderbilt Assessment Form - Parent Informant
• NICHQ Vanderbilt Assessment Follow-Up Form - Teacher Informant
• NICHQ Vanderbilt Assessment Follow-Up Form - Parent Informant
• Parent Interview for Dyslexia
• Teacher Observation Questionnaire for Dyslexia
• Asperger's Recommendations
• Parent Recommendations for ADHD
• Classroom Strategies for ADHD Students
• Central Auditory Processing Deficit
• Dysgraphia
• Consent for Release Form
• Educational Evaluation
• M-CHAT Form

 

General

• Standard UIL Camp and School Form (check your school's website to see if they provide a specific form)
• TB-Lead Screening Questionnaire
• Patient Satisfaction Survey
• Registration Form Update
• Consent Form 18-Year-Old
• Teenager Well Visit Questionnaire