Forms have been made available to you on this website for your convenience. Whether you are an individual preparing your documents prior to your appointment or a business looking for a bit more company oriented form, all forms are available here for you to print.
Choose the category that best describes you or your needs and click on the link to take you to the appropriate form(s) you may need. Please ensure that the forms are as complete as possible for a more efficient check-in process when you arrive at the clinic.
Choose the category that best describes you or your needs and click on the link to take you to the appropriate form(s) you may need. Please ensure that the forms are as complete as possible for a more efficient check-in process when you arrive at the clinic.
ASQ ONLINE SCREENING
Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2, 4, or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.
Please click on the link below for the questionnaire to complete.
ASQ Questionnaire
ASQSE Form (or social emotional)
NEW PATIENT FORMS
Medication list - If you are taking any medications, please take the time to write the name of your medication(s), and dosage(s) you are taking. Having this list will help our providers make a better assessment of your health during your visit.
Please click on the link below for the questionnaire to complete.
ASQ Questionnaire
ASQSE Form (or social emotional)
NEW PATIENT FORMS
- Patient Demographics Form
- Financial Policy Form
- 2020_sliding_fee_discount_schedule_application.pdf (only if applying)
- Patient Privacy Information Notice
- Medical_Records_Release_Form
Medication list - If you are taking any medications, please take the time to write the name of your medication(s), and dosage(s) you are taking. Having this list will help our providers make a better assessment of your health during your visit.
For business related forms, please click here.
established/returning patients
If you were a patient that has been seen at this clinic in the past, but has not been back or seen by one of our providers in the last two (2) years, you will need to complete the forms designated to the "New Patients" as a lot may have changed since your last visit with us. For those who are established, the following must be completed.
- Patient Demographics Form - must be completed if changes have occurred regarding your status, addresses, phone number, employer and insurance information. This form must reflect the most up to date information about you.
- Financial Policy Form - this form is required once every two years only.
- Intake Form (2-9 years of age)/Intake Form (10+ age) - the intake form must be completed each time you visit the clinic, or once every week if consecutive visits at the clinic have occurred.
- Sliding Scale Form (only if applying or reapplying).
- Mychartor.providence.org/mychart/ - Access your test results, manage your appointments, communicate with your doctor, refill prescriptions (by mail only).
