Forms

We need several items of information from you before we can deliver care for your child. We can’t get this information from other places you may have given it, including other providers, the hospital, or previous clinics, due to HIPAA laws and other confidentiality requirements.

In an effort to make it as painless as possible, here are the forms you may need in pdf-fillable format.

Remember:
  • You’ll have to fax it, mail it or bring it with you to your appointment, because emailing it IS NOT SECURE and could lead to identity theft
  • If you don’t have it completed by your appointment time, you’ll have to fill it out by hand at the office, and your appointment will be delayed

Nurse Inquiry Form - to ask a question of the nurse, fill out this form, print it out and fax it to us. Someone will respond within 24 hours. For established patients only. NOT FOR EMERGENCIES.

New Patient Form - All new patients need the first 3 forms filled out before their appointment. The last page is optional.

Fax it, mail it or bring it with you to your appointment. NOTE: emailing it IS NOT SECURE and could lead to identity theft. If not completed by appointment time, you’ll have to complete it at the office, your appointment will be delayed and you might have to be rescheduled.

Foster Child New Patient Form - if you are a foster parent of a new patient, please fill this form out before their appointment.

Transfer/Release Medical Records Form - This form can be used to transfer records into or out of Cottonwood Pediatrics. It must be FULLY completed.

Step-Parent Consent to Treat Form - when the spouse of a remarried parent brings the child to the clinic

Grandparents Consent to Treat Form - also babysitters, friends, aunt/uncle, etc.

Teenager Annual Consent to Treat Form - must be 16 or older

We reserve the authority to decide, in our sole discretion, to require a parent to be present regardless of any consent a parent may have signed.