Screening and Patient Forms
Each form below can be completed securely from any phone or computer browser. When complete, please press Submit.
|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.
|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.
|HIPAA Privacy Policies||Informational Only||
|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.
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|