Office Forms
All of our forms are saved in Portable Document Format (PDF). If you do not have a PDF reader already you can download it from Adobe. We recommend Adobe Fill and Sign for form completion. Please see Document Transmission in our practice guide.
- Registration Form– Please complete this form prior to your first visit.
- Financial Policy– Complete this form prior to your first visit.
- Additional Registration Contacts– Complete this form in addition to the Registration Form when adding more than 2 contacts to an account.
- New Patient Medical History Form– Complete this form to help us get familiar with your health prior to your visit.
- Permission to Treat– Grants permission for caregivers (other than parents and/or legal guardians) to check-in underage patients.
- Authorization to Share Information with Family and Friends – Grants access to medical information as specified for patients age 18 and over.
- Records Release Form– Request to send Piedmont Pediatrics records to another facility.
- Records Request Form– Request to release records from another facility to Piedmont Pediatrics.
School, Sports, and Camp Forms
Many of your child’s activities require special forms that must be completed by a physician.
School, sports and camp forms can typically be completed during your child’s annual well visit. However, the VIRGINIA HIGH SCHOOL LEAGUE (VHSL) FORMS MUST BE COMPLETED AFTER MAY 1st for the upcoming school year. Please make sure to bring your forms to the appointment with the health history completed.
If you are dropping forms off at the office, your portion (demographics and health history) MUST BE FILLED OUT. We will complete these forms in 48-72 hours. Please check the form requirements and/or schedule a new well child check up if it has been over 12 months since your child’s last well visit.