(Or returning patients not seen within the last 12 months)
Prior to your first visit with us, please print and complete the following forms online before your appointment:
Patient Information Form – Submit Online
HIPAA Privacy Consent Form- Submit Online
Health History Form- Submit Online (Requires Patient Portal account. If no account, refer to the printable version)
Prenatal Consults only
*Only use this form if your first appointment is a prenatal consult. If this applies to you, complete ONLY this form
Telehealth- Virtual Visit Consent Form
Additional Printable Forms:
Release of Medical Records
If you would like to release patient records from Pediatric Surgical Associates to a different clinic, provider or person, please fill out the form below.
If you would like to release patient records to Pediatric Surgical Associates from a different clinic, provider or person, please fill out the form below.
Temporary Authorization to Accompany a Minor
Complete this form for temporary authorization by a patient’s legal guardian(s) for a non-custodial adult to accompany a minor to their appointment.
To view the forms listed, you will need Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.