Office Forms

Unfortunately, paperwork is a necessary part of going to the doctor, and having insurance claims filed on your behalf. In order to speed up the time that you spend in the office, the following forms are provided here for you to download, complete, and bring with you to the office.

Some of these forms are part of our registration (and yearly re-registration) process. Others may deal with medical records or with particular evaluations that your pediatrician may use. See the individual descriptions for more information.

2017 Information and Authorization

We need current information about you and your child so that we can contact you if needed and submit insurance claims on your behalf. The new “Red Flag Law” requires that we keep a list of people who may consent to treatment for your child on your behalf. This form also allows you to specify others who have your permission to bring your child to the doctor. We need it on file even if you don’t authorize anyone but yourself.

Medical Record Release Authorization

Sometimes sending a copy of the medical record is necessary. You may complete this form and return it to our office to have records sent to us from another physician’s office, or to obtain a copy of your child’s records at Laurelwood.

Initial Health Questionnaire

If your child is a new patient to Laurelwood, please download and print this form to supply us with important health history.

Developmental Screen 18 Months

If you are coming to the office for an 18 month checkup, please complete this form and bring it with you to that visit.

Developmental Screen Age 5-10

If you are coming to the office for a checkup between ages 5 and 10, please complete this form and bring it with you to that visit.

Developmental Screen Age 11-18

If you are coming to the office for a checkup between ages 11 and 18, please have your child complete this form and bring it with you to that visit.

ADHD Evaluation Form – Parent

The Vanderbilt Parent Assessment form used in evaluating children who may have ADD or ADHD. Please print and complete this form prior to appointments for evaluation of learning or ADD / ADHD concerns.

ADHD Evaluation Form – Teacher

The Vanderbilt Teacher Assessment form used in evaluating children who may have ADD or ADHD. Please print and have your child’s teacher complete this form prior to appointments for evaluation of learning or ADD / ADHD concerns.