Village Pediatrics

Trust In Our Care

Village Pediatrics

RESOURCES

Patient Resources

Our staff looks forward to meeting you and discussing your child's pediatric care. We strive to keep our appointments on time, as scheduled. Prior to your appointment, we encourage you to fill out the patient forms that are located on this website so that you can accelerate your check-in process. Please download, print and complete the forms and bring them with you to your appointment. If you are unable to download our patient forms, then it is recommended that you arrive to your appointment between 15-30 minutes early so that you can have ample time to fill out the appropriate forms.

Prescription History

Prescription History

Consent to Obtain Prescription History

Financial Policies

Financial Policies

Information on Village Pediatrics' Financial and Office Policies

Health History Questionnaire

Health History Questionnaire

Medical and Family History Questionnaire

HIPAA

HIPAA

Authorization and Consent Agreement for Office Policies and Privacy Practices

Patient Information

Patient Information

Patient, Parent and Insurance Information Form

Portal Communication Release

Portal Communication Release

Consent forms to use Patient Portal to access your child's records

Treatment Permissions

Treatment Permissions

Caretaker Authorization for Medical Treatment

Consent to Treatment

Consent to Treatment

Medical Authorization Form

*Individual results are not guaranteed and may vary from person to person. Images may contain models.