Patient Forms | Coastal Pediatrics

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

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Coastal Pediatrics Forms

We’re very excited to have you join the Coastal Pediatrics Family!

Please click on any of the forms below to download and print

New Patient Paperwork

NEW PATIENT PAPERWORK

Please print and complete this packet and bring it to our office at your first visit. It needs to be completed for each child in the family.

Annual Update Paperwork

ANNUAL UPDATE PAPERWORK

Please print and complete this packet and bring it to our office at your annual visit. It needs to be completed for each child in the family.

Vanderbilt Forms

VANDERBILT FORMS

The Vanderbilt Form is a rating scale that can be completed by parents and teachers to assess performance in children.

PARENT FORM

TEACHER FORM

Anxiety Screening Forms

ANXIETY SCREENING FORMS

The Screen for Child Anxiety Related Disorders form is a parent or child completed rating scale that assesses how the child is feeling.

PARENT FORM

Transition to Adult

TRANSITION TO ADULT

Please print this packet and review it with your child transitioning to adulthood.

MALE PACKET

FEMALE PACKET

SPORTS PHYSICAL FORM

COVID-19 Vaccine Form

COVID-19 VACCINE FORM

Please print and complete this form and bring it with you for your visit.

COVID-19 VACCINE CONSENT FORM
(12+ YEARS OLD)

COVID-19 FACT SHEET
(12+ YEARS OLD)

COVID-19 VACCINE CONSENT FORM
(5-11 YEARS OLD)

COVID-19 FACT SHEET
(5-11 YEARS OLD)

Join the Coastal Pediatrics Family

Lifelong habits are formed early on, so let’s make sure they’re healthy ones! Learn more on how we can help your growing family.