Save time by completing required patient forms before you arrive.
Pediatric & Adolescent Associates is dedicated to providing the best pediatric care for your child and making it as easy as possible on you.
Below you will find many forms that are needed for your child’s appointments. We have divided them into sections to help make it simple for you. If you'd like, you may fill them out beforehand and bring them to your child's appointment in order to expedite the check-in process.
YEARLY UPDATE FORMS:
* NEW* These forms you are able to fill out online and submit!
- Patient Profile Form
- Patient Consent to Treat Form
- Financial Policy
- Schools & Daycare Release
- Paperwork Packet- pdf
- 18 & Older Paperwork
- Newborn Patient Profile Form
- Consent to Treat Form
- Financial Policy
- School & Daycare Release
- Intial History Questionnaire-Newborn
18 YEARS & OLDER:
- Patient Profile for 18 & Over - Please print,complete & bring to visit
- Consent to Treat for 18 & Over - Please print, complete & bring to visit
- Financial Policy for 18 Over - Please print, complete & bring to visit
- School Release - Please print, complete & bring to visit
- Facts about HIPAA
- FMLA Release
- Immunization Record Request Form
- Insurance Update Form
- Secondary Insurance Form
- Transfer of Care/ Release of Medical Information
- KY High School Athletics Association (KHSAA) Form -updated Aug 2020
- 504 Plan Instructions
- Request for Electronic Communications
- Authorization for Release of Information Records Request from Other Providers
With 11 pediatricians on staff, our team of doctors work diligently to provide the children of Central Kentucky and the surrounding areas with the most up-to-date, evidence-based care available. With 2 locations, Pediatric & Adolescent Associates works hard to make great pediatric care available when you need it most.
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.