Patient Forms
For your convenience, below is a list of the most commonly used forms in our offices. If you are a new patient, you can fill out the new patient forms and bring them with you to your appointment.
Forms can be downloaded using Adobe Acrobat and completed prior to your office visit. If you do not have Adobe Acrobat, you may download it here.
CHKD Pediatric Practice Forms
- New Patient Registration Form
- Formulario de Registro para el Paciente (New Patient Registration Form)
English
- Medical Records Release Form (Authorization To Use Or Disclose Protected Health Information)
- Medical Records Release Form - Including Substance Use Disorder Information
- Medical History Form
En español
- Autorización para Utilizar o Divulgar Información Protegida de Salud (Medical Records Release Form)
- Autorización para Divulgar Registros Médicos que Incluyen Información sobre Abuso de Sustancias (Medical Records Release Form - Including Substance Use Disorder Information)
- Historial de Salud Para Paciente Pediatrico (Medical History Form)
Virginia School Entrance Form (For high school and middle school students)
Consent for Telehealth Consultation
Treatment and Payment Consent
Unaccompanied Minor Authorization Form
Consent for Telehealth Consultation
Telehealth Guide for Parents and Patients
Webex
Zoom
ADHD/ADD
NICHQ - Assessment Scale
NICHQ - Assessment Follow-up
Hospital Forms
CHKD Notice of Privacy Practices
Patient Rights and Responsibilities
Your Rights and Responsibilities
Financial Assistance Application Form
Financial Assistance Application Form/Solicitud Para Asistencia Financiera
Medical Records Release Form
Medical Records Release Form - Including Substance Use Disorder Information
Other Forms
Adult Patient's Authorization to Disclose PHI
CommonWell Health Information Patient Opt-Out Form
Attestation Regarding Reproductive Health Care (Professionals and Providers Only)