Questions about this section? Need to email forms to us? Send them to bkoehler(at)fourseasonspediatrics(dot)com!
Please fill out forms before your visit (save time and make your visit hassle free). Find the appropriate form, fill them out on your computer and print them out. They can be faxed (383-3255), mailed or turned in at the time of your appointment.
The following forms that are in PDF format can be filled out on your computer. Or you can print them first and then fill them out on paper. Please remember that some of these forms require your signature in pen, and can not be completed on the computer.
- These forms require parent/guardian signature in blue or black ink, please print out on paper.
- Pediatric history questionnaire
- Registration to office
- Consent for treatment and office policy
- Consent for proxy
- HIXNY Registration
- Records Release from old doctor to Four Seasons
- Records Release from Four Seasons to new doctor
- Insurance Change
- Address Change
- Email/Fax request to a designated third party (e.g. daycare, school).
- Only one child per form.
- Email/Fax request form to parents/patient only.
- More than one child can be on this form.
Parent Forms (for parents who receive vaccines in our office):
Well Visit Forms - We require you to bring your current insurance card and photo ID to each visit to our office. These rules were enacted to prevent identity theft and are for your protection.
The vaccine information statements can now be viewed online before your appointment. Click Here to review online – GO GREEN AND REVIEW TO SAVE PAPER.
- First Visit Thru Two Month Visit
- Four Month Thru Six Month Visit
- Nine Month Thru Fifteen Month Visit
- Eighteen Month Thru Two and One-Half Year Visit
- Three Year Visit
- Four Year Thru Five Year Visit
- Six Year Thru Eleven Year Visit
- Twelve Year Thru Seventeen Year Visit
- Eighteen Years and Older Visit
Flu Vaccine Screening Forms: Fill out these forms if you are coming in for a flu vaccine. One form for each person vaccinated:
ADHD Forms (please note that we require return of these forms BEFORE we will schedule your appointment)
For Routine Every 6 month follow up, fill out this form:
- ADHD Parent Feedback Form – Parents fill out this form. Mail back to us (or drop off BEFORE your appointment).
AND ONE of these (if not an Adolescent). Please do not have multiple teachers fill out forms – if there is more than one teacher to give input, kindly ask them to jointly fill out the forms:
- ADHD School Fall Feedback Form – Parents can email this form to the school teacher. This form is used for teachers who are new to your child (typically in the fall). Once completed mail back to us (or drop off BEFORE your appointment).
- ADHD School Spring Feedback Form – Parents can email or mail this form to the school teacher. This form is used for teachers who have rated your child before (typically in the spring). Once completed mail back to us (or drop off BEFORE your appointment).
OR this form if an Adolescent:
- ADHD Adolescent Self Form – Adolescents (typically in High School) may find it difficult to find teacher feedback. Instead they can choose to rate themselves. Once completed mail back to us (or drop off BEFORE your appointment). If age 18 or older, stop by the office to pick up the Adult Self Assessment Form
For New Evaluations (Initial Evaluation):
- ADHD New Evaluation Forms:
- Parent Packet A – this form is for parents to fill out for a NEW evaluation
- School Packet B – this form is for your child’s teacher to fill out for a NEW evaluation
- ADHD New Medication Evaluation Form – this form is ONLY used when your child is FIRST started on a medication (Usually for the first month of starting a new medication) and allows a weekly evaluation of medication by the parent and the teacher.
- ADHD Parent Handbook – this is a description of ADHD, how it changes with age, resources, books, and website. One of the most reputable web sites is www.chadd.org
Adobe Reader (or Acrobat) is required to view these pdf forms. Click here to download Adobe Reader for free.
Microsoft Word or Open Office is required to view these word documents. Click here to download Open Office for free.