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Patient Forms
Click on the links to open a patient form.
Use the print button to print these forms to
fill out. Our forms can be viewed with Adobe
Acrobat Reader.
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New Patients
Welcome to Medical Center Pediatric Center. We
invite you to read our
welcome
letter, which explains our office
policies. Before coming to your first
appointment at our office, please fill out the
new patient forms, with the applicable
disclosure form.
1.
Welcome Packet
2.
Registration Form
3.
Pediatric Patient Questionnaire
4.
Medical Family History
5. Ages and Stages Questionnaires (ASQs):
6.
CDC immunization schedule under 6 years old
7. M-CHAT
This notice describes how medical
information about your child(ren) may be
used and disclosed. We are required by law
to protect the privacy of your child(ren’s)
protected health information. This document
also explains how you can gain access to
your child(ren’s) medical information and
who to contact should you have a complaint.
Please read this document carefully and sign
the acknowledgement form.
Returning
Patients
If you have not been seen in over a year, or
if there has been any change in your personal
information and/or your medical history, please
print and complete the
Update Family
Information Form
and bring with you to your appointment.
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Patient
Portal Register and Login Click here to
Register and/or Login
(you will be redirected to a new page):
PrognoCIS Patient Portal |
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