Downloadable Forms for Pediatric Patients
We offer three convenient options to make sure that these forms will be available for your provider at the time of your visit.
- Scan and email them to admin@vickerypeds.com.
- Fax them to (678) 990-2505 (Attn: Front Office Staff).
- Hand-deliver them to the front office staff for scanning into your child’s chart.
You may download the required forms you are looking for below.
New Patient Medical Forms
Patient Portal
If you are a new patient, please pre-register for the patient portal.
New Patient Forms and Documents
- New Patient Form Package
- HIPPA Privacy Notice and Acknowledgement Form
- Authorization to consent to Medical Treatment of Child
- Vaccination Policy
- Medical Chaperone Policy & Request/Denial Form (ages 11 and up)
General Medical Forms
- Request Form for medical letters and other medical forms
- Release of Medical Information Form
- Military Facility Medical Release DD2870 Form
- HIPPA Privacy Notice and Acknowledgement Form
- Authorization to Consent to Medical Treatment of Child
- Vaccination Policy
- General Financial and Administrative Policies
Child Well Visit Forms
- Well Child Services Waiver
- Well Child Questionnaire Ages 1 Month
- Well Child Questionnaire Ages 2–6 Months
- Well Child Questionnaire Ages 9 Months to 10 Years
- Well Child Questionnaire Ages 11 Years & Up
- Developmental Screener 9 months
- Developmental Screener 18 months part 1
- Developmental Screener 18 months part 2 MCHAT
- Developmental Screener 24 months MCHAT
- Developmental Screener 30 months
- Developmental Screener 5 years
- Well Child Services Financial Policy
Pediatric ADD/ADHD Forms
The following forms will help you prepare for your child’s ADD/ADHD appointments and save you time in the office. If you would like to complete the forms online – here is the link.
Initial ADD/ADHD Evaluation
- ADHD Assessment and Treatment Protocol
- ADHD Cardiac Screening
- NICHQ Vanderbilt Assessment Scale: Teacher Informant
- NICHQ Vanderbilt Assessment Scale: Parent Informant
ADD/ADHD Follow-up Maintenance Visits
- NICHQ Vanderbilt Assessment Follow-up: Teacher Informant
- NICHQ Vanderbilt Assessment Follow-up: Parent Informant
ADD/ADHD Resources
- Basic Facts: What Every Parent Should Know Before Starting a Child on Medication
- The Use and Abuse of Psychostimulant Medication: Tips for Parents and Teens
- ADHD Educational Rights
- Why Is My Child Having Trouble in School?
- ADHD and Coexisting Disorders
- ADHD and Disruptive Behavior Disorders
- ADHD and Tics and Tourette Syndrome
Medical Forms for Autism, Developmental and Other Appointments
These forms and resources can be useful to parents prior to appointments for autism, developmental, behavioral and other pediatric visits.
Developmental Screening
- Developmental Screening (Ages & Stages) 9 Months
- Developmental Screening (Ages & Stages) 18 Months
- Developmental Screening (Ages & Stages) 30 Months
Autism
Depression and Substance Abuse
