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We have organized all of the forms you will need for your child’s health visits by age. Please click on the age group for details on which forms you should fill out prior to your visit and bring all forms filled out to your appointment along with medication list and/or inhalers.

Newborns or New Patients:

1. Patient Registration Form (PDF)
2. Private Health Information Form (PHI) (PDF)
3. HIPAA (PDF)
4. Billing & Financial Policy (PDF)

2 months to 15 months:

1. Registration (if new address or insurance) (PDF)
2. PHI Authorization Form (if there are any changes) (PDF)

18 month to 2 years:

1. Registration (if new address or insurance) (PDF)
2. PHI Authorization Form (if there are any changes) (PDF)

3 years to 12 years:

1. PSC-17 Girl (PDF)
2. PSC-17 Boy (PDF)
3. Registration (Required annually or with new address or insurance) (PDF)
4. PHI Authorization Form (if there are any changes) (PDF)

13 years to 17 years:

1. PHQ-9 (PDF)
2. Registration (Required annually or with new address or insurance) (PDF)
3. PHI Authorization Form (if there are any changes) (PDF)

18 years & up:

1. PHQ-9 18+ (PDF)
2. HIPAA (PDF)
3. Registration (patient should fill out) (PDF)

CT Daycare & School Health Assessment Forms 

Below are copies of the Connecticut Health Assessment Forms. During your visit, a staff member will ask if you need either form completed. If so, your clinician will complete the appropriate form and provide you with a printed copy before you leave.

If you need an additional copy after your visit, you can call either office or send a message through the patient portal to request one. Completed forms can be accessed through the portal, printed for pickup at either office, or faxed directly to a designated recipient upon request.

1. Day Care Health Assessment Form (PDF) – Also known as the Yellow form
2. School Health Assessment Form 5 years (PDF) – Also known as the Blue form

PMA Forms

1. New Patient Registration Form 2017 (PDF)
2. Notice of Privacy Practices (PDF)
3. HIPAA Acknowledgement (PDF)
4. Billing and Financial Policy (PDF)
5. Medical Records Instructional Letter (PDF)
6. PHI Authorization Form (PDF)
7. Authorization for Release of Patient Records (PDF)