• In This Section
• Health Library
• Way to Grow
• Visitor Information
• Your Child's Stay
• Parenting Classes and Resources
• Patient Rights and Responsibilities
• Your Child's Medical Records

Forms can be downloaded using Adobe Acrobat and completed prior to your office visit.

CHKD Pediatric Practice Forms

Patient Registration

• New Patient Registration Form

Medical History Forms

• Medical Records Release Form (Authorization To Use Or Disclose Protected Health Information)
• Medical History Form

COVID-19 Permission to Return to School/Childcare 

• Permission to Return to School/Childcare Form

Virginia VFC forms

• Vaccines for Children (VFC) Program

School Entrance Forms

• Virginia School Entrance Form (For high school and middle school students)
  
• North Carolina School Entrance Form

Sports Physical Forms

• VHSL Sports Physical Form
• NCHSAA Sports Physical Form

Consent Forms

• Telehealth Consent Form
• Telehealth Consent Form (Spanish)
• Treatment and Payment Consent - Virginia
• Treatment and Payment Consent - North Carolina
• Treatment and Payment Consent - Virginia (Spanish)
• Unaccompanied Minor Authorization Form
• Authorization and Consent
• Teenager Access to MyCHKD Patient Portal Authorization

Telehealth

• Parent/Patient Telehealth Information
• Webex Quick Start
• Zoom Quick Start (Short Version)
• Zoom Quick Start (Full Version)

ADHD/ADD

• ADHD cardiac screening questionnaire
• NICHQ - Assessment scale (for parents) 
  • NICHQ - Assessment follow-up (for parents)
• NICHQ - Assessment scale (for teachers) 
  • NICHQ - Assessment follow-up (for teachers)

Hospital Forms

Patient Privacy Forms (CHKD Notice of Privacy Practices Form)

• English Version of NPP
• Aviso Acerca De Las Practicas De Privacidad

Additional Hospital Information & Forms

• Your Rights and Responsibilities
• Financial Assistance Application Form
• Medical Records Release Form (Authorization To Use Or Disclose Protected Health Information)
• Adult Patient's Authorization to Disclose PHI