Forms & Questionnaires

For your convenience, you can find new patient forms and questionnaires for several visit types below. We understand that no one enjoys juggling clipboards, paperwork, and children in the waiting room, so the following forms are provided for you to download, complete and bring with you to your appointment. See descriptions of the forms below. By clicking on the underlined link, a pdf should open in a new window. If you have any trouble, please email us for help - info@primarycarepeds.org
New Patient Forms

 

Demographics Form -  In order for us to submit claims to your insurance on your behalf, written permission is required and updated yearly.

 

Practice Guidelines  -  Please review our practice guidelines and policies.

 

Consent to Treat  -  We are required by law to keep a list of other people that you have authorized to bring your child to the clinic and to consent for your child's treatment.

 

Medical Records Request  -  For continuity of care, we review your child's previous medical records. We need your written permission to request records. 

 

HIPPA Notice of Privacy Practices - Please review HIPPA notice carefully

Sports Physical Form

 

Your child's sports physical may be required within a certain time frame from the start of participation. Check with your school or coach prior to scheduling an appointment for a sports physical. 

 

Clearance is required for middle school and high school only and remember to wear clothes you can easily move in when you come to the clinic. 

 

 Sports Physical (English Version)           Sports Physical (Spanish version)

Wellness Check Questionnaires

 

Age  4 - 16 years | Emotional and Behavior Screening:

English Version

Spanish Version

 

Age 18 months and 24 months | Autism Screening Form:

English Version

Spanish Version

ADHD Evaluation & Recheck 

 

Our office uses the following form for ADHD visits. This is only for children ages 6 years and older. Please download and complete the form prior to your child's appointment.

 

ADHD symptom checklist

Questionnaire for new mothers

 

At the 1 & 2 month well baby check up visit, we use the following questionnaire:

 

EPDS form  (1 & 2 month well baby check)

Primary Care Pediatrics

8081 Highway 51 North

Millington, TN 38053

Children are a gift from the LORD.
Psalms 127:3
  • Facebook - Grey Circle
  • LinkedIn - Grey Circle

© 2016 -20 by Primary Care Pediatrics, All rights reserved