Patient Forms
Additional Reminder:
COVID-19 Clinic Policies:
– Additional siblings are NOT allowed to attend appointments
– Masks are mandatory for all persons over age 3 who enter our facilities
– A maximum of TWO legal guardians are permitted to attend appointments
Failure to comply with any of these policies will result in cancellation of the appointment upon arrival.
Thank you for your cooperation and understanding.
Please follow the links below to to complete your paperwork.
Forms must be submitted no later than two days prior to the appointment.
NEW patients:
Health History Form (preferred method)
Alternate link
Patient Demographic Form
HIPAA Privacy Consent
Virtual Visit Consent Form
*Telehealth patients only*
RETURNING patients:
*Required only if most recent appointment was over three years ago
Health History Form (preferred method)
Alternate link
PRENATAL patients:
Prenatal Health History Form
Additional Forms as Needed
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 if you are not a legal guardian but will be the bringing patient to the appointment. This must be completed and signed by the child’s LEGAL guardian prior to the appointment in order to be seen.