Patient Forms
Forms and Documents for Your Child’s Care
Find the forms and documents you may need before your child's visit or when updating your family's information with Franklin Pediatric Associates. Download the appropriate form, complete it as instructed, and bring it with you or return it to our office when requested.
Not sure which form you need? Contact our office and our team will be happy to help.
01 — New Patient Registration
Provide the information needed to register your child as a new patient.
Download Form →02 — Health History
Share important information about your child's health and medical history.
Download Form →03 — Consent to Treat
Provide consent for Franklin Pediatric Associates to provide care for your child.
Download Form →04 — Privacy (HIPAA) Acknowledgment
Acknowledge receipt of information about our privacy practices.
Download Form →05 — Financial Policy Agreement
Review and acknowledge the practice's financial policies.
Download Form →06 — Credit / Debit Card on File Authorization
Authorize Franklin Pediatric Associates to keep a payment card on file.
Download Form →07 — Modified Vaccine Schedule Agreement
Complete this form if you have arranged a modified vaccine schedule with the practice.
Download Form →08 — Divorced / Separated Household Form
Provide information about custody and household arrangements for your child.
Download Form →09 — Caregiver Consent
Authorize another adult to bring your child to the office when you are unable to attend.
Download Form →10 — Authorization to Release Medical Records
Authorize the release or transfer of your child's medical records.
Download Form →Do not email completed forms containing private health information unless the practice provides an approved secure method.
We're Here to Help You Get Started
Preparing for a new pediatrician doesn't have to be complicated. If you have questions about becoming a patient, preparing for your child's visit, or understanding your insurance, our team is here to help.
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