Patient Forms

We have forms available online for you to view and print. Completing necessary paperwork prior to your child’s visit helps quicken the check-in process. Please take a minute to complete all applicable areas on the form prior to dropping it off or mailing it to our office.

We will complete most child care, publicprivate school and college medical forms within three business days. *There is a $10.00 fee for each form requested. Please include this payment with your form(s) to expedite the process.

Forms Packets

• Newborn Paperwork (New Patient)
• New Patient Registration Paperwork

Individual Forms

• COVID Vaccine Consent Form, Pfizer EUA 
• Telemedicine Consultation Form
• Family History Form (Yearly Update)
• Prenatal Forms
• Authorization for Treatment (In absence of Parents/Guardians)
• HIPAA rev 11/1/2017
• Financial Policy

Individual Forms for Dr. Shropshire's Patients (Developmental Pediatrician)

• New Patient Registration - BH
• Patient Registration 18yrs+ - BH
• Developmental Pediatrics Intake Questionnaire

School & Sports Forms 

• School Entrance Health Form
• VHSL Athletic/Sports Participation Form

Screening Forms

Vanderbilt ADHD Forms

Initial Assessment Form (complete prior to initial ADHD appointment)

• Vanderbilt Teacher Initial Assessment 
• Vanderbilt Parent Initial Assessment (English)
• Vanderbilt Parent Initial Assesment (Espanol)

Follow-up Forms (complete after treatment started)

• Vanderbilt Teacher Follow Up
• Vanderbilt Parent Follow Up

Anxiety Related Disorders

• Scared Patient AKG
• Scared Parent AKG

Autism

• M-Chat R/F

Behavioral Health forms for Therapy

• Initial Therapy Visit information 
• Initial therapy intake form (English) 
• Initial therapy intake form (Spanish)
• Patient registration and agreement (minors)
• Patient 18 yrs and over registration and agreement
• Telemedicine Consent Form for Therapy (English)
• Telemedicine Consent Form for Therapy (Spanish)
• Therapy Billing information
• Release of Information (English)
• Release of Information (Spanish)

Depression

• PHQ9 Patient Questions
• PHQ9 Parent Report

Parent Survey

• How are we doing? (Survey)

Medical Records Release Policy

When requesting your child's medical records, a Medical Records Request Form must be completed and returned to Pediatrics Associates of Alexandria. Once the completed form has been received, our office will contact the parent or guardian informing them of their cost for processing a copy of their records. Payment is typically made by credit card over the phone with no additional fee. Please allow approximately two weeks from receipt of the payment for the records to be processed and received.

• Medical Records Release Form
• Medical Shot Records Release Form

Specialists Referrals Policy

Pediatric Associates of Alexandria asks that you submit requests for referrals at least five business days prior to your scheduled appointment with your child's specialist. Please provide: the child's full name, date of birth, parent or guardian's name, contact phone number, name of insurance, date of appointment, specialist's complete name, office phone number, and diagnosis or reason for office visit. Once the referral is complete, the parent or guardian will be notified by phone that it is ready for pick-up at our office. Referrals will not be faxed.

It is the responsibility of the parent or guardian to submit a referral request at least five business days prior to the child's appointment with the specialist. Only under extreme emergency circumstances will same day referrals be approved and completed. Referrals cannot be back dated, and in most cases, your insurance requires 24 to 48 hours notice to approve (giving us authorization).

• Referrals Request Form