Patient Forms

For your convenience, below is a list of the most commonly used forms in our offices.

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

Please note: Forms may require a $10 fee depending on your insurance. These forms include school forms, college forms, and camp forms. Forms must be completed in your provider's office, not through the MyCHKD patient portal.

Patient Registration/Registro de pacientes

New Patient Registration Form
Formulario de Registro para el Paciente (New Patient Registration Form)

Medical History Forms/Formularios de historial médico

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

AutorizaciÃ³n para Utilizar o Divulgar InformaciÃ³n Protegida de Salud (Medical Records Release Form)
AutorizaciÃ³n para Divulgar Registros MÃ©dicos que Incluyen InformaciÃ³n sobre Abuso de Sustancias (Medical Records Release Form - Including Substance Use Disorder Information)
Historial de Salud Para Paciente Pediatrico (Medical History Form)

Virginia Vaccines for Children (VFC) Program

VFC Program Patient Eligibility Screening Record

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/Formularios de consentimiento

Consent for Telehealth Consultation

Telehealth Consent Form | Consentimiento para consulta a Traves de telesalud

Treatment and Payment Consent

Treatment and Payment Consent | Reconocimiento/Sonsentimiento Para Tratamiento Y Pago

Unaccompanied Minor Authorization Form

Unaccompanied Minor Authorization Form | Autorizacion para que un menor no acompanado pueda recibir tratamiento medico

Authorization and Consent

Teenager Access to MyCHKD Patient Portal Authorization

Telehealth

Consent for Telehealth Consultation

Telehealth Guide for Parents and Patients

Parent/Patient Telehealth Guide

Webex

Webex Quick Start

Zoom

ADHD/ADD

NICHQ Assessment for Parents & Teachers

NICHQ – Assessment Scale

NICHQ – Assessment Scale Follow Up

Hospital Forms

Patient Privacy

CHKD Notice of Privacy Practices

Additional Information and Forms

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

Authorization for CHKD to Obtain and/or Exchange Protected Healthcare Info

Other Forms

Adult Patient's Authorization to Disclose PHI

CommonWell Health Information Patient Opt-Out Form