Richmond Pediatrics

Screening and Patient Forms

CHADIS
At Richmond Pediatrics we strive to provide the best care possible for your child. In an effort to create this outcome, we are excited to announce our partnership with Child Health and Development Interactive System: CHADIS. CHADIS is a state-of-the-art service that allows you to complete developmental and health questionnaires online prior to your child’s next visit. CHADIS was founded by experienced pediatricians with the goal of providing better care and support to kids and families. By completing these questionnaires prior to your child’s appointment, your child’s medical provider will be able to review the results and be ready to discuss them with you during your child’s visit. An added benefit for you is that the forms are filled out at home, online, and at your convenience. We encourage all patients to fill out these forms prior to your child’s appointment. Depending on the age of your child, the forms should take between 5 and 15 minutes to complete.  FAQs about CHADIS Those forms will be available on our Patient Portal. Please call us if you do not have access or need additional assistance. Once signed in from a browser, click Fill Milestones at the bottom of the home screen.

Important: The mobile app does not currently support completing forms. Please sign into the Patient Portal from any browser to complete forms using the Fill Milestones button.

Each form below can be completed securely from any phone or computer browser. When complete, please press Submit.

 
Form Who Completes? Description Language
New Patient Packet Legal Guardian or Patient

Please complete this packet prior to your first appointment to maximize the amount of time you spend with the doctor. 

 English
Release of Records (Online)

Release of Records (Print Version)

 Legal Guardian or Patient

To authorize release of medical records to Richmond Pediatrics from another office or to request medical records from Richmond Pediatrics.

Please complete this form prior to your first visit if you are a new patient.

 English
HIPAA Privacy Policies Informational Only

Please read our privacy policy to understand how we use and disclose your medical information.

 English
Financial Policy Informational Only Richmond Pediatrics Financial Policy English
Copays and Well Child Checks Informational Only Please read and sign the following acknowledgement of copay information at Well Child Check-ups.  We do our best to make payment expectations available at the start of your visit, but final charges do vary by your insurance and what is ultimately covered in your appointment. English
Informed Consent for Treatment of Minors Legal Guardian

To have someone other than a parent (such as a grandparent or babysitter) bring your child in for a visit, and to share relevant health information with them, please fill out and sign this form.

 English

 

Please complete the appropriate form as soon as possible before your scheduled appointment. Please call the office if you are unsure which form to complete. If this is a telehealth appointment, a staff member may also call you before your appointment with additional instructions. Each form below can be completed securely from any phone or computer browser. When complete, please press Submit.

 
Form Who Completes? Patient Age Language
2 week checkup Mother 7 days to 21 days English
1 month checkup Mother 3 weeks to 6 weeks of age English
2 and 4 month checkup Mother 6 weeks to 4 months of age English
6 month checkup Primary Caregiver 6 months of age English
9 month ASQ (Patient Portal Only) Primary Caregiver 9 months of age English or Spanish
9 month checkup Primary Caregiver 9 Months of age English
12 month checkup Primary Caregiver 12 months of age English
15 month checkup Primary Caregiver 15 months of age English
18 month checkup (Patient Portal Only) Primary Caregiver 18 months of age English or Spanish
2 year checkup Primary Caregiver 2 years of age English
MCHAT (Patient Portal Only) Primary Caregiver 16 months to 28 months English or Spanish
2 and 1/2 year checkup Primary Caregiver 2 and 1/2 years of age English
30 month ASQ (Patient Portal Only) Primary Caregiver 2 1/2 years of age English or Spanish
3-5 year checkup Primary Caregiver 3-5 years of age English
6-8 year checkup Primary Caregiver 6 – 8 years of age English
9-12 year checkup  Parent Primary Caregiver 9 – 12 years of age English
11-12 Year — Patient Patient 11 – 12 years of age English
13-17 year checkup — Parent Primary Caregiver 13-17 years of age English
13-17 year checkup — Patient Patient 13 – 17 years of age English
18 years and over checkup — Patient Patient 18 years or older English

 

Other Forms

Important Reading Material