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Print or download the forms you need:
New Patient Forms:
Patient Information Form
Consent by Proxy for Non-Urgent Pediatric Care/Release of Information
Patient Financial Responsibility Disclosure
Insurance Information Request
Pediatric Patient History
HIPAA Medical Release Form
HIPAA Notice of Privacy Practice Consent Form
ADD/ADHD Forms:
ADD ADHD Instruction Letter
ADHD Medical History
Vanderbilt Assessment Initial
(Parent & Teacher forms)
Vanderbilt Assessment Follow-up
(Parent & Teacher forms)
Additional Forms:
Modified Checklist for Autism in Toddlers
18 Year Old: Extension Of Care Letter
18 Year Old: Patient’s Financial Responsibility Disclosure
School Sports Physical Forms:
1589 – Medical Consent
1588MS – Athletic eligibility for Middle School Students
1588HS – Athletic eligibility for High School Students
For additional information, please visit the School District website:
The School District of Palm Beach County
Emergencies
|
Routine Visits
|
Sick Visits
|
Immunizations
|
Newborn Parenting
|
Safety
|
Locations
|
Staff
|
Hospitals
