Forms

General Forms

Some forms are also available to fill out online through our Patient Portal

Privacy Notice Receipt
Privacy Notice
Preauthorization for Adolescents (to come to office alone)
Office Registration (Spanish)
Office Registration
Office Registration (for patients aged 18 or older)
Immunization Schedule
Consent for Proxy (Permission for Alternate Caregiver)

 

Pre-participation forms

Kindergarten or Elementary school form
Virginia High School League Athletic Participation Form (Spanish)
Virginia High School League Athletic Participation Form
(fill out completely before coming to office)

Medical authorization

Albemarle County
Charlottesville City
Fluvanna County
Greene County
Louisa County - Jouett Elementary School
Louisa County - Trevilians Elementary School
Louisa County High School
Orange County Public Schools

Release of information forms

Information coming to Pediatric Associates
Main/Adolescent Office
North Office
West Office

Information being sent from Pediatric Associates
Main/Adolescent Office
North Office
West Office

Check up forms

Family history form
Prenatal form

12 month visit
Tuberculosis screen

18 month visit
MCHAT (autism) screen
MCHAT (autism) screen - Spanish

2 year old visit
MCHAT (autism) screen
MCHAT (autism) screen - Spanish

5 year old visit
Tuberculosis screen

College check up
Tuberculosis screen

what's new

August 14, 2018
Back to School Sleep

August 14, 2018
What is Influenza

August 14, 2018
A Guide to Teething

August 14, 2018
Bedwetting

the adolescent center

Our Adolescent Center is a comprehensive medical and mental health-care center designed to meet the special needs of teenagers and young adults.