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
October 25, 2018
Keeping Your Family Healthy this Winter
October 25, 2018
Depression in Adolescents
October 25, 2018
Is it a Cold or the Flu?
August 14, 2018
Back to School Sleep
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.