Patient Forms | Pediatricians in Tampa Bay | Offices in Hillsborough, Pasco, and Pinellas

Patient Forms

New Patients

New patients must review and acknowledge receipt of this information prior to your first visit.

For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.

A registration form is required each year to obtain current information for patients and parents.

Please complete this form to have your child's medical records released to our office, from your child's previous health care provider.

Please complete this form to notify us as to the individuals who may bring your child to the office for treatment. Without this form, we will be unable able to provide medical care to your child if they are not accompanied by the parent(s)/legal guardian listed on the Patient Registration Form.

If you are new to PHCA and your child is age 6 months or older, please bring this completed form to your child's first office visit.

Please complete this form for your child's first office visit. 

This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.

This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.

For your convenience, we offer a service to keep your credit card on file for any charges related to office visits and outstanding balances. Please complete this form and bring it to the office at your next visit if you would like to opt-in to this service. 

Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.

For parents-to-be who would like a prenatal meeting before baby arrives, please complete this short questionnaire to help us get to know you.

Parent Vaccines

Parents - please complete this screening if you will be receiving flu or pertussis vaccine from your child's pediatrician. 

Established Patients

For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.

A registration form is required each year to ensure current information is on file.

This registration form is for patients 18 years and older or foster parents and is required each year to obtain current information for patients and parents. 

Please complete this form to notify us as to the individuals who may bring your child to the office for treatment. Without this form, we will be unable able to provide medical care to your child if they are not accompanied by the parent(s)/legal guardian listed on the Patient Registration Form.

Our complete notice is available for your review. A parent/guardian will be asked to sign off on receipt of this notice at the first visit each year. Patients ages 18 years and older will be asked to sign off on receipt of this notice at the first visit after they reach legal age. 

For patients ages newborn to 17 years old: This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.

This form contains detailed billing policies and a representative list of items with potential fees and charges, to ensure you are better informed at the time of services and prior to the arrival of a billing statement. A completed form is required each year.

For your convenience, we offer a service to keep your credit card on file for any charges related to office visits and outstanding balances. Please complete this form and bring it to the office at your next visit if you would like to opt-in to this service. 

Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.

Please fill out this form to have your child's medical records released FROM Pediatric Health Care Alliance to another doctor or medical facility.

Developmental Screenings

COVID-19 Vaccine

Patients will need to complete this CDC screening checklist prior to receiving the COVID-19 Vaccine.
1 page

This Fact Sheet contains information to help you understand the risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine. (Ages 12 yrs and older)
(7 pages)

General information about the Vaccine Adverse Event Reporting Sytem
(1 page)

V-safe is a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination.
(1 page)

This Fact Sheet contains information to help you understand the risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine. (Ages 5-11 yrs)
(7 pages)

Patient Vaccines

Please complete this form to authorize the Alliance to administer the influenza vaccine to your child. Prior to signing this form, you will need to read the Vaccine Information Statement from the Centers for Disease Control and Prevention.

If your child is age 2 years or older, he or she may be eligible to receive the intranasal flu vaccine, FluMist. If you would like your child to receive this type of flu vaccine, please complete this form for review with your pediatrician.

If your child is scheduled for a vaccine-only visit for any immunization, please bring this completed form to the visit.

Physicals

This form acknowledges your child's patient confidentiality rights, and parents should complete this form for adolescent patient visits (ages 12-18 years).

When our pediatricians see adolescent patients, we request that the patient complete a short, confidential questionnaire. Adolescent patients can give a completed questionnaire directly to the pediatrician to protect his or her feeling of confidentiality, or the form can be provided for completion during the visit. Confidentiality is promised to adolescent patients as part of our working relationship. We do encourage patients to discuss these issues openly with their families. We will inform a parent or guardian if a patient poses a serious risk to themselves or to others. 

Please have your child complete this form prior to his or her scheduled sports physical.

ADD/ADHD

Form 1 of 2 Parents should print and complete this form prior to your child's appointment for evaluation of ADD/ADHD. Please bring both completed forms to your appointment.

Form 2 of 2 Parents should print and have your child's teacher complete this form prior to your child's appointment for evaluation of ADHD. Please bring both completed forms to your appointment.

Form Form 1 of 2 Complete these forms only if your pediatrician requests them for a follow up visit.

Form Form 2 of 2 Complete these forms only if your pediatrician requests them for a follow up visit. (Updated 9/19/2012)

This form will be provided to you at the time of prescription refill for ADD - ADHD medication(s). This states our policy regarding follow up and monitoring of your child's status, based on medical industry and health insurance quality care standards.

Weight Management

After your child's initial Weight Management visit, a follow-up visit will be scheduled. Please bring this completed questionnaire with you.

This diary is to help keep track of your meals, water, physical activity, and screen time to help everyone follow the guidelines for a healthy family. Please use this diary each week, and bring completed diaries to your child's weight management visit.

If your pediatrician schedules a Weight Management visit, please bring this completed questionnaire with you.

Asthma

This form is used to assess your child's level of asthma. Please complete it before your next appointment and ask the office staff to place it in your child's chart. The pediatrician or nurse practitioner will review the questionnaire with you.

Billing

This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.

If you need a copy of your child's medical records for any reason, please review and complete this form and turn it in at your pediatrician's office.