INTEGRATIVE PEDIATRICS

​Forms

HIPAA 
Notice of Privacy Practices
Acknowledgment and Consent 

Financial Policy 
Financial Policy 

New Patient
Registration Packet (includes Financial Policy, HIPPA Consent, and Patient Registration Form) 
Prenatal Packet
Patient Health History Form 

Records Transfers
Transfer to Integrative Pediatrics
Transfer to Another Clinic

Immunizations
Visit and Vaccination Schedule at Integrative Pediatrics 
Vaccination Glossary
For Information about specific Immunizations, click here 

Autism Screening
M-Chat – used to screen for Autisms at 18-24 months 

Vanderbilt Assessments – used to screen for ADD and ADHD in school age children 
   -Parent Assessment 
   -Parent Assessment Follow-Up
​   -Teacher Assessment 
   -Teacher Assessment Follow-Up

Miscellaneous
Consent to Discuss/Disclose (required for age 14+)
Homeopathy History Form 
Lead Screening Questionnaire
Portal Registration Instructions 
Authorization for Consent to Treatment
Authorization to Use and Disclose Protected Health Information
MVA Billing Information
Non-Discrimination Statement

Connect

Share


This website and all information and links are educational and not intended to diagnose or treat.
​You are advised to consult with your health care provider before implementing anything you may have learned here or elsewhere. 
Website by MediaCor