Forms

Forms

There will be appointments where we will ask you to fill out one or more forms prior to being seen. These forms help us get information important to your child's diagnosis or plan of treatment. We can mail these forms to you but it may be easier for you to download them from this page. They are in PDF format. If you don't have the free Adobe Acrobat® Reader, follow the link on this page to download it.

ADHD Forms

Packet of "Helpful Hints" handouts

Initial Evaluation for School Problems Visits
Elementary Students (gr. K-5)
Middle/High School Students (gr. 6-12)
Adult (post high-school)

For Patients transferring ADHD care to PIP from another clinic or doctor

Forms for ADHD follow-up appointments
Elementary Students (gr. K-5)
Middle/High School Students (gr. 6-12)
Adult (post high-school)

 

Teacher forms only
Elementary Teacher forms only
Middle/High School Teacher forms only

Teacher forms only (for transferring)
Elementary Teacher forms only
Middle/High School Teacher forms only

Teacher forms only (follow-up)
Elementary Teacher forms only
Middle/High School Teacher forms only

Adolescent Visit Questionnaires
Teens: Print out and complete the appropriate form and bring with you to your visit

Preteen (11-12 yrs)
Teen (13-14 yrs)
Teen (15-17 yrs)
Young Adult (18 yrs and older)

Allergy and Asthma Questionnaires
Allergy/asthma visit questionnaire
Allergy evaluation and testing consent

Medical Records Forms
Release of Medical Records Authorization
      (To have records sent to PIP, or from PIP to another clinic)
Release for verbal communication of Medical Information
      (For patients 18 years of age or older or emancipated minor)
Patient Consent for Medical Care
      (This form will be kept in child's chart, and includes a place to designate others
        who may occasionally bring a child in for medical care, such as a daycare
        provider, grandparent, or others the parent/guardian designates.)
Temporary Authorization to Consent to Treat My Child
       (For use when a parent or guardian plans to be out of town and child(ren) will be
         in the care of someone else during that time.)
♦  Minnesota Health Care Directive
       (A worksheet and form which lets family and medical professionals know your
        wishes about health care if you are unable to communicate them yourself.)

New Patient Questionnaires
New patient history

Well Child Visit Questionnaires
Click here to go to PIP's Well Child Exam and Immunization page. You will be able to
          open, print out, and complete questionnaires to bring along to your child's visit.

 

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