School, Day Care, Sports and Health Forms

Forms for New and Returning Patients

Being a parent or guardian means filling out a lot of forms! If your child is a new patient, you can get a head start by downloading the requested forms below, filling them out and bringing them to your first appointment. If you are a returning patient, you only need to fill out the Patient Information sheet below.

Authorization for Use
Financial Policies
Immunization/Check-Up Schedule
Medication History Consent and Pharmacy Information Form
New Patient Family Medical History Form
New Patient Past Medical/Social History
New Patient Registration Form
Notice of Privacy Practices (HIPPA)
Patient Information
Receipt of Privacy Practices (HIPPA)
Release of medical information for Over 18 year-olds
Transferring Medical Records

School & Sports Forms

Most schools, day cares and sports organizations require medical authorization forms before allowing your child to enroll or participate. Due to the volume of requests we receive, we ask that you give us 48 hours to complete your child’s forms. After that, you may pick them up at your convenience. Please note: In order for us to properly complete any forms, your child needs to have had a check-up within the past year.

Dispensing Medication at School
Fairfield Schools Medication Form
Lakota Schools Medication Form
Mason Schools Medication Form
ODJFS Child Medical Statement (for Child Care Facilities)
Ohio High School Athletic Association
Physical Examination Form
Princeton Schools Medication Form
School Medication Form

Behavior Evaluation Forms

Contract for Safety
MFQ (child version) Mood/Depression evaluation
MFQ (Parent)

PHQ-9 Depression evaluation
Beck's Depression Inventory
PSC (parent and child) Emotional/Stress evaluation
SCARED (parent) Anxiety evaluation
SCARED (child)
Vanderbilt Assessment—Parent Initial
Vanderbilt Assessment—Parent Follow-Up
Vanderbilt Assessment—Teacher Initial
Vanderbilt Assessment—Teacher Follow-Up

Miscellaneous Forms

Cincinnati Children’s Hospital Pre-Procedure Physical Exam Form
Food Allergy Action Plan for Anaphylaxis
Teen Phone Contract
Quitting Smoking