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 – 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
– Printable
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.