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.
Immunization/Check-Up Schedule
Notice of Privacy Practices (HIPPA)
Receipt of Privacy Practices (HIPPA)
Address or Insurance Change Form
New Patient Registration Packet
Authorization for Release of Health Information
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
Behavior Evaluation Forms
Contract for Safety
PHQ-9 Depression evaluation
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