Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice

Additional Patient Forms

Thank you for choosing Allied Pediatrics. We look forward to caring for your child. Listed below are our patient forms. If you prefer, you may download these forms in advance, complete them and bring them with you to your first visit.

All our forms are in PDF format, so you will need Adobe Acrobat installed on your computer in order to view them.

Telemedicine Visits:

Authorization and Consent to Participate in Telemedicine Consultation and Services Use this form to authorize and consent to the use of interactive video technology to communicate with a health care provider at a distance.

Virtual Visit Policy (PDF) – This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Sports Physical Form:

TN and GA Sports Physical form – Please feel free to print and complete the health history portion before the visit with the provider. The school system requires sports physicals to be completed April 15 or after for that school year.

Miscellaneous Forms:

Recommended Vaccine Schedule – This is the vaccine schedule that the American Academy of Pediatrics and Allied Pediatrics recommends.

Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente (PDF)

Authorization For Alternate Caretakers – Use this form to authorize alternate caretakers to bring children to their appointments at Allied Pediatrics.