PLEASE NOTE: Due to COVID-19
We allow only ONE parent or guardian to accompany the patient to the appointment. Failure to adhere to this policy may result in cancellation or postponement of the appointment.
Please complete the following forms online prior to your appointment.
Patient Information & Demographic Form – New Patients or those not seen in previous 12 months
HIPAA Privacy Consent Form – New Patients
Health History Form – For all new and returning pediatric patients
Submit Online (Requires Patient Portal account. If no account, refer to alternate version)
Prenatal Health History Form- For patients having a Prenatal consult
*Only use this form if your first appointment is a prenatal consult. If this applies to you, you do not need to complete the Health History Form listed above.
Telehealth- Virtual Visit Consent Form
Additional Forms – NOT REQUIRED unless otherwise informed by our staff
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.