Clinic Forms

New Patient Forms

• Patient Rights and Responsibilities
• Patient and Family Medical History Form
• Authorization to Treat in Absence
• Permission to Treat
• Authorization to Release Medical Information to Pediatric Associates of the NW
• Authorization to Release Medical Information from Pediatric Associates of the NW
• HIPAA Privacy Notice
• HIPAA Receipt
• Financial Policy
• Behavioral Health Authorization to Release/Disclose Confidential Information

Developmental Forms

• ASQ 9 Month Questionnaire (9 Month Well Child)
• M Chat (18 Month Well Child & 24 Month Well Child)
• ASQ 18 Month Questionnaire (18 Month Well Child)
• ASQ 24 Month Questionnaire (24 Month Well Child)
• ASQ 30 Month Questionnaire (30 Month Well Child)

Behavioral Health Forms

• Accessing Behavioral Health Services

ADD/ADHD Evaluation Forms

• Parent Forms
• Teacher Forms

Pain Reduction Handouts

• Infancy Pain Preparation 
• Child and Teen Preparation

Nutrition Forms

• Food Diary 
• Menu Planning
• Goal Setting Calendar
• Controlling Your Child's Cholesterol

Frequently Used Forms

• Oregon Sports Physical Form
• Washington Sports Physical Form
• Boy Scouts Part A, B, and C 
• Girl Scouts Health Form