September 16th 2019
For Patients & Families
For a full listing of our phone numbers, see the directory below. You can also view medical records and manage your appointments using our patient portal.
Forms
For your convenience, we have provided downloadable forms for each of our divisions below. Additional information may be found on the division pages.
Pediatric Lung and Allergy Center
To learn more about these forms, review our PLAC: Planning Your Visit page.
New Patient Forms
- Registration Form English | Spanish
- Notice of Privacy Practices English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices for parent/guardian of a minor child English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Privacy Practices for adult patients English | Spanish
- Financial Responsibility Statement English | Spanish
- New Allergy Patient Intake Form English | Spanish
- New Allergy Patient Instructions English
If you are being seen for Immunotherapy (Allergy Shots), you may also complete the following forms:
- Immunotherapy (Allergy Shots) Consent Form English
- Immunotherapy (Allergy Shots) Serum Renewal Consent Form English
Pediatric Surgical Group
To learn more about these forms, review PSG’s Planning Your Visit page.
New Patient Forms
- Registration Form English | Spanish
- Financial Responsibility Statement English | Spanish
- Notice of Privacy Practices English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) English | Spanish
- Medical Permission Form English | Spanish
Pediatric and Adolescent Sleep Center
To learn more about these forms, review our Planning Your Visit to PASC page.
New Patient Forms
- Patient Registration Form English | Spanish
- Notice of Privacy Practices English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) English | Spanish
- New Patient History Form English | Spanish
- Pediatric Symptom Checklist English | Spanish
- Patient Portal Proxy Form English | Spanish
Established Patient Forms
Additional Consent Forms
- Medical Permission Form English | Spanish
- Authorization to Use and/or Disclose Protected Health Information Form with instructions English | Spanish
- Request to Review and/or Obtain a Copy Protected Health Information (PHI) Form with instructions English | Spanish
Sleep Study FAQs
Sleep Study FAQs – English | Spanish
Sleep Study Only Forms
- Patient Registration Form English | Spanish
- Notice of Privacy Practices English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) English | Spanish
- Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) English | Spanish
- Sleep Log (Please fill this out 2 weeks prior to your child’s sleep study.) English | Spanish