Forms

Forms

School, daycare, camp, sports and WIC forms can be completed at the time of your child’s well visit at no charge. Please give your forms to our receptionist when you check in. Any additional forms brought or mailed in after a scheduled visit require at least two business days to process and will incur a charge of $5.00 per form. Please include a self-addressed, stamped envelope if forms are to be returned by mail. We tend to experience a high volume of requests for forms prior to the new school year and we will do our very best to complete your forms in a timely manner.

School & Camp Forms

Health Assessment Record — State of Connecticut Department of Education

Early Childhood Health Assessment Record — State of Connecticut Department of Education

Camp Form

Office Forms

Acknowledgement of Receipt of Note of Privacy Practices

Designation of Personal Representative

HIPPA Authorization for Release of Patient Records

Registration Form

Financial Policy

Credit Card on File Authorization