Forms

EXISTING PATIENTS

Authorization Form: Use this form to request a full set of medical records when leaving our practice, or to send any part of your child’s medical records directly to a third party. Full paper records cost $10 per patient to cover the cost of printing and/or mailing. (Fee is waived for patients with MassHealth.) Digital copies are free. Once you've completed the form, you can send it to us via fax or mail or upload it to us via our Patient Portal or our file upload form.

Food Allergy Action Plan: Fill this out if your child needs an allergy action plan for school and bring to your next visit. Be sure to check off the appropriate box(es) for symptoms, and complete the medications section.

M-CHAT Form: Complete this form prior to your child's 18-month and 2-year visits.

NEW PATIENTS

Registration & Consent Forms: New patients should complete these forms before the first appointment. The consent form refers to the four policies below.

Vaccine Policy: We require all patients to adhere to recommended immunization schedules. This notice outlines our policy.

Financial Policy: This notice outlines our payment policies and your responsibilities with regard to health insurance.

Confidentiality Policy: This notice describes how we approach confidentiality with teenage patients.

Notice of Privacy Practices: This notice describes how medical information about your child may be used and disclosed, and how to access this information.