Upload documents or pictures/copies of insurance cards
– or –
Download & complete forms listed below, save to your device, then click and Upload.
Forms
Administrative Forms
Online Forms
New Patient Information Online
(PDF fillable)
Baby Pre-Registration Online
(PDF fillable)
Foster Placement Information
PDF Only Forms
Patient Privacy and Consent to Treat
(PDF fillable)
Non-parent authorization
(PDF fillable)
Authorization for 16Y old and older
(PDF fillable)
Transfer Records Authorization
(PDF fillable)
Authorization for Parents (18Y+ patients)
(PDF fillable)
Behavioral Forms
ADHD
Vanderbilt Initial Packet
(PDF fillable) Entire packet must be completed and brought to initial appointment. If no or incomplete packet, appointment will be rescheduled.
ADHD follow-up:
Vanderbilt Parents (PDF fillable)
Vanderbilt Teachers (PDF fillable)
Anxiety:
Screen for Child Anxiety Related Disorders
Child – need one
Parent – need one
Depression:
PHQ-9 modified for Adolescents
Daycare, School & Sports
Immunization records: pick-up copy during business hours or request it to be mailed to address on file.
OR Request your child’s immunization records directly from the state immunization registry, PDF available.
School health assessments: if your child is current on wellness checks, you may request a copy. You can choose to pick it up or have it mailed to the address on file.
Sports Physicals: fill out the packet from the school. Then we will fill out according to the exam.
Per KSHSAA regulations, the check-up should be done after May 1st. Call us for more information.