Forms and Registration

You may access the following forms to assist us with your care. Please print and complete the following forms, and bring them to your appointment.

New Patient Forms

• New Patient Packet
• 18+ Year Packet

Yearly Updates

We require a yearly update to the following forms:

• Demographic Information
• Acknowledgement of Financial Policy

Consent Forms

It is generally our policy that all patients under 18 years of age must be accompanied to all appointments by a parent or legal guardian. Learn more about our policy.

• Consent to Treat– Use for a one-time case where you will not be able to accompany your child to the office. A signed, faxed "Consent to Treat" form, sent by the parent with a valid phone number where the parent can be reached during the appointment. The parent MUST be available.
• Power of Attorney – If the parent will not be available (out of the country, etc.) during the appointment, a "Power of Attorney" form must be filled out and brought by the caretaker to any appointments while the parents are unavailable.
• 18+ Year Financial Consent Form – If the patient is over the age of 18, they must have a signed consent on file.
• 16+ Year Consent Form – If the patient is over the age of 16, they must have a signed consent on file to be seen without a parent/guardian present. However, a parent/guardian still needs to be present at any appointments requiring procedures (including vaccines) to sign consent at the time of the visit.
• Teen Screen Parent Letter – At well checks for teenagers (ages 13-17) we have your child fill out a Teen Screen survey yearly. This letter provides an explanation of the survey your child fills out and why we do it. We'll have you sign at the bottom giving your consent at your child's well visit.

Administrative Forms

• Medical Records Release – Authorization for Release of Medical Records

Patient Portal Registration

• How to sign up for your patient portal with an email invitation.
• How to sign up for your patient portal without an email invitation.

Behavior and Development Forms

These Vanderbilt Parent & Teacher Rating Forms for ADD/ADHD may be requested as part of an evaluation for ADD/ADHD. Please complete and bring them with you to your child's appointment or fax to our office at (480) 860-8498 with the attention to your child’s physician.

• Vanderbilt Parent Initial
• Vanderbilt Parent Follow-Up
• Vanderbilt Teacher Initial
• Vanderbilt Teacher Follow-Up
  

Sports/School Physical Forms

• AIA Form - Sports clearance form accepted by most schools and teams. Please fill out the first 4 pages and bring the packet with you to your child's well visit. If your child already had a well visit within the past 12 month, please drop off the completed packet to the front desk or attach the completed form to a portal message and we will return the signed forms to you within 72 hours.

*These forms require Adobe Acrobat Reader. Click the Adobe logo above to download.