Forms

School, Daycare, Camp and Sports Forms

SUBMIT YOUR FORM NOW

To guarantee the fastest completion, please use the link above to submit your form. You can direct any inquiries to our office at forms@centercitypediatrics.com. Please allow 10 business days for processing. Please review our Forms Policy prior to submitting your request.

Telemedicine Consent

Please read the consent form in advance of your telemedicine appointment. You will be asked at the time of your call to agree to the terms before the appointment can begin.

• Download Consent Form

Transferring Records to Our Practice

• Medical Records Transfer

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Privacy Guidelines & Consents

• Consent to Treat a Minor
• Authorization to Disclose over 18

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CCP Developmental Screening Tools

If you choose to fill these out at home, these tools are to be brought into the office where they will be tabulated and scored by a doctor.

• Complete List: Developmental, Behavioral and Emotional Screening Tools
• Edinburgh (EPDS)
• Modified Checklist for Autism in Toddlers (MCHAT)
• Survey of Well-Being of Young Children: 12 months (SWYC)
• Survey of Well-Being of Young Children: 24 months (SWYC)
• Pediatric Symptom Checklist (PSC17)
• Patient Health Questionnaire (PHQ9)
• Teen Screen
• Vanderbilt ADHD Diagnostic Caregiver Rating Scale
• Vanderbilt ADHD Diagnostic Teacher Rating Scale

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Leaving Our Practice

• Chart Transfer Request