More forms coming soon!
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New Patient Forms - coming soon!
To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.
Permission to Speak Forms
Records Release Form
CPPA Records Release Form - Print and sign this form if you need your records transferred from Concord Pediatrics to a new primary care office.
Authorization for Access to Health Information - Print and sign this form if you would like Concord Pediatrics to be able to exchange information with another healthcare provider (for example, if you would like your child's primary care provider to speak with your child's therapist). [/storage/app/media/authorization-to-access-health-information.pdf]
Attention Deficit Hyperactivity Disorder (ADHD) Forms
NICHQ Vanderbilt Assessment Forms are one tool we use to diagnose Attention Deficit Hyperactivity Disorder. If you have concerns about your child and ADHD, please discuss those concerns with one of our medical providers prior to using these forms.
If your child's medical provider has directed you to fill out the NICHQ Vanderbilt Assessment Scale and to distribute them to your child's teacher(s), please use the links below to access a printable copy.
- NICHQ Vanderbilt Assessment Scale - Parent Forms
- NICHQ Vanderbilt Assessment Scale - Teacher Forms
- NICHQ Vanderbilt Assessment Follow-up - Parent Forms
- NICHQ Vanderbilt Assessment Follow-up - Teacher Forms
The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist is designed to be filled out by an older teen or adult on their own. The form is designed to stimulate dialogue between a teen or adult patient and his or her medical provider and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD).
Food Allergy and Anaphylaxis Emergency Care Plan
Please print out and complete the form below and bring it to the office to be signed. (Please allow 24 hours for our providers to review and complete the form.)
- Food Allergy and Anaphylaxis Emergency Care Plan [Edited by Concord Pediatrics, P.A.]
- Original form from Food Allergy Research and Education (FARE) available here.
- Anaphylaxis Emergency Action Plan [from American Academy of Allergy Asthma & Immunology]
Asthma Action Plan