Patient Forms

New Patients

(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

HIPAA Privacy Consent Form

Health History Form

Health History Form (online version- only use this link if you are web-enabled for our Patient Portal. If not, refer to the printable version)

New Patient – Prenatal Consults only

*Only use this form if your first appointment is a prenatal consult. If this applies to you, complete ONLY this form

Prenatal Questionnaire

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.

Release of Medical Records Form

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.

Release of Medical Records Form

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.

Temporary Consent to Accompany a Minor Form

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.