Countryside Pediatric Care New Patient Forms
Below are the patient forms for our practice. We have combined the individual forms into packets to make it easier for you to download and print. Or you may choose to download and complete only the individual forms you need.
- New Patient Forms Packet – Please complete all the forms in this packet for new patients.
For your convenience you may download and print our forms individually. Please bring the completed documents to your first visit.
- Form to transfer records to our office
- Initial History Questionnaire
- HIPPA Consent Form
- New Patient Registration Form
- Office Financial Policy
- ADHD Evaluation Forms for Parents & Teachers
- ADHD Policy
- Notice of Privacy Practice (This is just for your information. You do not need to sign this or bring it to your visit)
- Patient Contact From
- Forms Administrative Fees Policy
- 18 Month Questionnaire
- 24 Month Questionnaire
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.
The Initial Visit
With all of the important information about our practice available on our website, you can feel confident that you and child are well-prepared for your first appointment. We look forward to meeting you. Countryside Pediatric Care – Patient Forms – Safety Harbor – Florida – 727-599-0893