Patient Forms

New Patients

(Or returning patients not seen in over one year)

 

Please print and complete the following forms online prior to your appointment:

Patient Information Form

HIPAA Privacy Consent Form

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

 

 

 

 

 

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.