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Girl 1Our medical forms have been made available for download for your convenience and ours.

Before treatment can begin, the appropriate forms must be completed. This can be done at the clinic or at your convenience any time before your appointment.

If your child is in the care of a non-parent while you are away, please complete the Healthcare Proxy form below. We may not be able to treat your child without the information required by this form.


Welcome Packet

We understand how emotional a visit to the doctor's office can be for you and your child.

Completing the forms in the below will save time for both you and our medical staff; especially if this is your first visit. They can expedite service and shorten your visit.

Select only the forms that are applicable to your visit. If it is your first visit, all forms are required.

Welcome Form
This form lists personal information and identification information for the child, parent or responsible party, and insurance coverage. For contact information, security, and billing reasons, this form must be completed before treatment can begin. Once the doctor has diagnosed the problem, treatment will follow. This form gives St. Augustine Pediatric Associates permission to take the next step and administer the prescribed treatment and care to the patient. The primary purpose of St. Augustine Pediatric Associates is to offer medical care to our patients. To ensure all patients get the care when they need it, scheduling appointments is required. Each no-show leaves an empty time slot where a sick child could have been seen. This form is an incentive to ensure our time is well spent in the care of our patients.

In the case of minors, at times, parents and/or guardians may require others to gain access, in whole or part, to a child's medical information. This form allows you to authorize up to four additional people access to this information.

Health History Form
To ensure the best and most correct treatment for the patient's condition, we need the patient's medical history. This form should be completed prior to treatment.

Medical Record Request
Many patients have necessary medical records or information stored in other medical facilities. This information may be necessary for current relative treatment. Completing this form gives other medical facilities permission to release this information to St. Augustine Pediatric Associates.

Additional Forms

HIPAA Privacy Notice
We must comply with HIPAA Law to ensure the safety and security of your personal information and healthcare information.

Healthcare Proxy Form
Going out of town? Leaving the healthcare of your child to a friend or relative? This form can help ensure HIPAA privacy and maintain legal control for the caregiver for a specified length of time. This form must be notarized and dropped of to our office or may accompany the caregiver at the time of the appointment. A photo ID will be required for the caregiver listed on the form.

Medical Record Release
If for any reason you wish to request our office to send medical information to any other facility, this form may be filled out and signed to show verification and permission for our office to do so.

ADD / ADHD Assessment Forms

These forms, provided by the American Academy of Pediatrics, are tools which parents and/or teachers can use to determine if, and to what level, children may have symptoms related to ADHD (attention deficit hyperactivity disorder).

Download the appropriate form; answer the questions as best you can, then:
If you are a parent, make an appointment with your doctor for continued assessment. Should you choose to download the teacher version and present it to your child's teacher(s), we recommend you include your doctor's name and address at the bottom for delivery direct to the office, or pick it up and deliver it personally.

BoyIf you are a teacher, you most likely received the form from a parent or guardian. Should you download the form, we recommend you share the information with the parent or guardian.

 

NICHQ (Parent)
This form should be completed, with ink, by the parent or guardian and returned to the doctor for the initial assessment appointment.

NICHQ (Teacher)
Your child’s teacher needs to complete this form, with ink, and return it to either the parent/gaurdian or directly to St. Augustine Pediatric Associates.

NICHQ Follow Up (Parent)
This form should be completed, with ink, by the parent or guardian and returned to the doctor for the initial assessment appointment.

NICHQ Follow Up (Teacher)
Your child’s teacher needs to complete this form, with ink, and return it to either the parent/gaurdian or directly to St. Augustine Pediatric Associates.


For more information, refer to contact information.

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*New* Patient Portal Website: https://staugpediatrics.etransmedia.com