Patient Forms Patient Forms

Patient Forms

* All forms are PDFs- Get FREE Acrobat Reader Here


New Patient Forms

Please print out these forms and bring with you to your first visit.

Please review your insurance coverage to know what items will be covered and not covered.


New Patient Registration forms page 1

New Patient Registration forms page 2


Family Medical History Form page A

Social Medical History Form page B

Past Medical History Form page C



PIAA Physical Form

(note fee outside Well Care visit - see amount of prepayment below in 'Misc Fees List')

Link to PIAA website to obtain current PIAA forms


Sports Questionnaire

(when forms are needed between Well Care visits-note fee below in 'Misc Fees List')

DHPA Sports Questionnaire Form


To Release records from DHPA to another provider or physician

Medical Records Release Form


To Bring in records to DHPA from another provider or physician

Request for Medical Records


Misc Forms -

Also see patient portal for easy

Rx and Referral requests

Prescription Renewal form Via Fax

Referral Request Form Via Fax

H1N1 Flu Mist Questionnaire

Misc Fees List


Behavior Assessment Form- Conners Questionnaire

Directions Page

Parent Questionnaire *

Teacher Questionnaire *

Sample Letter to School

Tools-Books, Support Groups

*Available in Office


Behavior Assessment Form-Vanderbilt Assessment Scale

Parent Informant- Page 1  Page 2

Teacher Informant- Page1  Page 2

Sample Letter to School

Tools-Books, Support Groups


Disclosure of Notice of Privacy Practices

Privacy Practices - Page 1

Privacy Practices - Page 2



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