Patient Forms
Please complete and print the following forms PRIOR to your visit.
This will help the staff to expedite your wait time.
Completing forms requires Adobe Reader:
New Patient Forms
HIPAA Privacy Notice
Consent To Treat
If either parent or legal guardian is unable to bring the child in the office this form must be filled out.
Record Request Form
Use this form if you are requesting your child’s records for a transfer either to our practice or from our practice.
HIPAA Privacy Notice
This is a copy of Village Pediatrics Privacy Notice which is in accordance with the law.
Over 18 Confidentiality Agreement
Any patient that is 18 years or older must provide us with this form regarding the confidentiality of their medical records.
Pre-Natal Form
Please fill out this form prior to your meeting with the physicians.