FORMS

In order to better serve you quickly and effectively the day of your child’s appointment, please print and fill out the required forms. If you have any questions about what forms are required, our office staff would be delighted to assist you.

Patient Demographic Update

Please fill out if you have a change of address or contact information. Download here.

New Patient Paperwork

Please fill out if you are not an existing patient. Download here.

Consent For Telehealth Services

Please fill out and give to receptionist. Download here.

Non-Guardian Permission Authorization Update

Please fill out if you give permission for an adult other than yourself or other legal parent/guardian to bring your child to future appointments, and/or authorize them to make decisions necessary to have the child properly treated in office or via telephone. Download here.

Medical Release Form

Please fill out if you are requesting that medical records be sent to or from Children’s International Medical Group. Download here.

Medical Records Fee Form

Please fill out this form as consent to the cost of obtaining personal medical records from Children’s International Medical Group. Download here.

Print Media Release

Please fill out this form if you consent to allow Children’s International Medical Group to utilize a photo of your child for general media purposes. Download here.

Sponsorship Form

Please fill out if you would like Children’s International Medical Group to sponsor an organization or event. Download Here.

Controlled Substance Treatment Agreement

Please fill out if you consent to allowing your child to be given controlled substances. Download here.

You are also entitled to information about your rights and responsibilities between you and your child’s healthcare professional. Please take some time to view the Patient Rights and Responsibilities Forms.